Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain

How long does tendinopathy last if left untreated? Natural history of the main tendinopathies affecting the upper and lower limb: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Natural history of disease refers to the progression of a disease process in an individual over time, in the absence of treatment. Understanding natural history of tendinopathies is key for clinicians to make accurate prognostic predictions and design effective intervention studies.

OBJECTIVE

To quantify the natural history of the main tendinopathies regarding pain and function and to compare outcomes between untreated individuals and those receiving treatment.

METHODS

A systematic literature search was conducted until February 2023, across PubMed, Cochrane, Embase and Scopus databases. Selection criteria included randomized controlled trials (RCTs) with a "wait-and-see" group and cohort studies with ≥3 months of follow-up reporting on pain and function-related outcomes. Standardized mean differences (SMDs) of "wait-and-see" groups were pooled using a random-effects inverse-variance model. Risk of bias was assessed using Cochrane Risk-of-Bias (RoB2), and quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

Six RCTs were included, encompassing 518 subjects with tendinopathy. Pooled results demonstrated significant pain (SMD = 0.30, 95%CI: 0.19-0.41) and physical function improvement (SMD = 0.38, 95%CI: 0.28-0.48). These estimates remained consistent regardless of age or follow-up duration. In rotator cuff tendinopathy, untreated individuals improved but did not fully recover at one year, with similar outcomes to other interventions (e.g., surgery). Subjects with lateral elbow, patellar and achilles tendinopathies when untreated, did not fully resolve symptoms within 12-16 weeks.

CONCLUSIONS

This review provides limited conclusions about natural history of tendinopathies. Future studies should incorporate true no-intervention groups to accurately reflect tendinopathy's natural progression.

Clinimetric Properties of the Working Alliance Inventory and Credibility Expectancy Questionnaire: Screening Options for Musculoskeletal Pain

OBJECTIVE

To investigate clinimetric properties of 2 surveys used to evaluate common factors in the patient-provider relation and present screener options for the assessment of common factors and report their correlation with pain and functional outcomes.

DESIGN

Observational cohort.

SETTING

Outpatient physical therapy.

PARTICIPANTS

100 individuals (58% women, mean age=34, SD=15; N=100) presenting to physical therapy with musculoskeletal pain in the following regions: 44% lower extremity, 36% spine, 19% upper extremity, 1% undetermined.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Participants completed the Working Alliance Inventory (WAI) and the Credibility and Expectancy Questionnaire (CEQ). Exploratory factor analysis (EFA) explored factor structure of the WAI and CEQ. Internal consistency was evaluated for scales derived from items retained based on factor loadings. Finally, options for screener tools were proposed and assessed based on their correlation to original surveys as well as pain and functional outcomes.

RESULTS

The data supported a 4-factor structure for the surveys. Some WAI items were excluded due to cross-loading. The derived four-factor scales demonstrated strong correlations with the original surveys (r=.89-.99) and exhibited good internal consistency (α=.824-.875). Two screening options were suggested: 1 retaining 11 of the original 18 items and the other comprising just 3 items. Both screening tools correlated with the original surveys and showed associations with improvements in pain and functional outcomes (r=-.21-.34).

CONCLUSION

The proposed screeners provide concise measurement options to facilitate use in clinical practice. These tools can aid in facilitating patient communication specifically addressing patient expectation and understanding the tasks required to enact behavior change.

Risk factors associated with nocebo effects: A review of reviews

Objective

This meta-review aims to identify and categorize the risk factors that are associated with nocebo effects. The nocebo effect can exert a negative impact on treatment outcomes and have detrimental outcomes on health. Learning more about its potential predictors and risk factors is a crucial step to mitigating it.

Methods

Literature review studies about the risk factors for nocebo effects were searched through five databases (PubMed, Scopus, The Cochrane Library, PsycINFO, and Embase) and through grey literature. Methodological validity and risk of bias were assessed. We conducted a thematic analysis of the results of the forty-three included reviews.

Results

We identified nine categories of risk factors: prior expectations and learning; socio-demographic characteristics; personality and individual differences; neurodegenerative conditions; inflammatory conditions; communication of information and patient-physician relationship; drug characteristics; setting; and self-awareness. We also highlighted the main biochemical and neurophysiological mechanisms underlying nocebo effects.

Conclusions

Nocebo effects arise from expectations of adverse symptoms, particularly when triggered by previous negative experiences. A trusting relationship with the treating physician and clear, tailored treatment instructions can act as protective factors against a nocebo effect. Clinical implications are discussed.

Identical movement control exercises with and without synchronized breathing for chronic non-specific low back pain:A randomized pilot trial

BACKGROUND

Exercise is a first-line treatment for chronic non-specific low back pain (CNSLBP). Exercise combined with specific breathing techniques have the potential to improve multifactorial outcomes. No previous studies, however, have compared outcomes between identical exercises with or without a specific breathing protocol in a uniform clinical study setting.

OBJECTIVES

1) To investigate the feasibility of combining synchronized breathing with movement control exercises and evaluate eligibility criteria, randomization procedures, and dropout rates. 2) To study the preliminary efficacy of the interventions on multifactorial outcome measures.

METHODS

Thirty subjects with CNSLBP were randomized into two groups. Both groups had four contact clinic visits where they received personalized home movement control exercises to practice over two months. The experimental group included a movement control exercise intervention combined with synchronized breathing techniques. Trial registration number: NCT05268822.

RESULTS

Feasibility was demonstrated by meeting the recruitment goal of 30 subjects within the pre-specified timeframe with enrolment rate of 24.8% (30/121). Synchronized breathing techniques were successfully adhered by participants. Home exercise adherence was nearly identical between the groups without any adverse events. Preliminary efficacy findings on pain intensity, disability, and self-efficacy in the experimental group exceeded the minimal clinically important difference. No such findings were observed in any outcome measures within the control group. Overall, multifactorial differences were consistent because nine out of eleven outcome measures showed greater improvements for the experimental group.

CONCLUSION

The synchronized breathing with movement control exercises protocol was feasible and may be more beneficial for improving multifactorial outcomes compared to identical exercises alone. Results suggested progression to a full-scale trial.

Placebo and nocebo effects of percutaneous needle electrolysis and dry-needling: an intra and inter-treatment sessions analysis of a three-arm randomized double-blinded controlled trial in patients with patellar tendinopathy

Objective

This study aimed to investigate the influence of potential placebo and nocebo effects on pain perception of percutaneous needle electrolysis (PNE) in individuals with patellar tendinopathy.

Methods

In this secondary analysis of a three-arm randomized double-blinded controlled trial, intra and inter-session pain perception data from 48 sporting participants with patellar tendinopathy between 18 and 45 years were investigated. Participants were divided into 3 parallel groups: "no-sham group" [PNE intervention], "single-sham group" [sham PNE by using dry needling], and "double-sham group" [sham PNE by using sham needles]. Every group received 4 sessions of the needling therapies targeting the patellar tendon over 8 weeks and was instructed to perform a unilateral eccentric exercise program of the quadriceps muscle on the affected side. Clinical and needle-related pain was assessed before, during, and after each treatment session using a visual analog scale.

Results

No differences were found between groups intra- or inter-session in terms of pain reduction (P = 0.424) despite clinical pain decreased in all groups since the first treatment session (P < 0.001). Furthermore, although the double-sham group showed a lower percentage of participants reporting needle-related pain during needle intervention (P = 0.005), the needle-related pain intensity after needle intervention was similar between groups (P = 0.682). Moreover, there were no group differences for the duration of pain sensation after any needle intervention (P = 0.184), extending in many cases beyond 24 h.

Conclusion

Needling therapies for individuals with patellar tendinopathy are prone to elicit placebo effects regarding clinical pain and nocebo effects regarding needling-related pain. Clinicians and physical therapists treating musculoskeletal pain conditions should consider the added value and potential mechanisms of action before routinely using needle techniques.

A Utilization Review of Patients That Respond to Low-Dose Naltrexone (LDN) for Chronic Pain at a Single Institution

Studies have demonstrated the benefits of LDN for various pain indications. This review describes the utilization of and response to LDN in patients with chronic pain within the William S. Middleton Memorial Veterans Hospital (Madison VA). This was a retrospective, single center, chart review of patients that were prescribed LDN for chronic pain. The primary outcome, change in subjective pain report via numeric rating scale (NRS), was analyzed through Wilcoxon Signed Rank Test and descriptive statistics. A total of 136 participants were included. Patients had an average pain score of 7.1 per NRS at baseline. At the initial follow up visit, participants had an average pain of 6.4 (p < 0.001). Additionally, 17.1% of patients had a greater than or equal to 30% pain reduction from baseline. At subsequent follow up, patients reported an average pain of 5.5 (p < 0.0001) per NRS. At the end of the study, 31.6% of patients were maintained on LDN at an average dose of 3.8 mg. This retrospective review demonstrated that LDN may be an effective modality for some chronic pain indications. Reported pain scores were significantly lower at initial follow up compared to baseline for the total population, and for patients with fibromyalgia (FM) specifically.

Epistemological Flexibility in Person-Centered Care: The Cynefin Framework for (Re)Integrating Indigenous Body Representations in Manual Therapy

BACKGROUND

Chiropractic, osteopathy, and physiotherapy (COP) professionals regulated outside the United States traditionally incorporate hands-on procedures aligned with their historical principles to guide patient care. However, some authors in COP research advocate a pan-professional, evidence-informed, patient-centered approach to musculoskeletal care, emphasizing hands-off management of patients through education and exercise therapy. The extent to which non-Western sociocultural beliefs about body representations in health and disease, including Indigenous beliefs, could influence the patient-practitioner dyad and affect the interpretation of pillars of evidence-informed practice, such as patient-centered care and patient expectations, remains unknown.

METHODS

our perspective paper combines the best available evidence with expert insights and unique viewpoints to address gaps in the scientific literature and inform an interdisciplinary readership.

RESULTS

A COP pan-professional approach tends to marginalize approaches, such as prevention-oriented clinical scenarios traditionally advocated by osteopathic practitioners for patients with non-Western sociocultural health assumptions. The Cynefin framework was introduced as a decision-making tool to aid clinicians in managing complex clinical scenarios and promoting evidence-informed, patient-centered, and culturally sensitive care.

CONCLUSION

Epistemological flexibility is historically rooted in osteopathic care, due to his Indigenous roots. It is imperative to reintroduce conceptual and operative clinical frameworks that better address contemporary health needs, promote inclusion and equality in healthcare, and enhance the quality of manual therapy services beyond COP's Western-centered perspective.

Adjunctive electrophysical therapies used in addition to land-based exercise therapy for osteoarthritis of the hip or knee: A systematic review and meta-analysis

Objectives

To review evidence for effectiveness of electrophysical therapies (EPTs), used adjunctively with land-based exercise therapy, for hip or knee osteoarthritis (OA), compared with 1) placebo EPTs delivered with land-based exercise therapy or 2) land-based exercise therapy only.

Methods

Six databases were searched up to October 2023 for randomised controlled trials (RCTs)/quasi-RCTs comparing adjunctive EPTs alongside land-based exercise therapy versus 1) placebo EPTs alongside land-based exercise, or 2) land-based exercise in hip or knee OA. Outcomes included pain, function, quality of life, global assessment and adverse events. Risk of bias and overall certainty of evidence were assessed. We back-translated significant Standardised Mean Differences (SMDs) to common scales: 2 points/15% on a 0-10 Numerical Pain Rating Scale and 6 points/15% on the WOMAC physical function subscale.

Results

Forty studies (2831 patients) evaluated nine different EPTs for knee OA. Medium-term effects (up to 6 months) were evaluated in seven trials, and one evaluated long-term effects (>6 months). Adverse events were reported in one trial. Adjunctive laser therapy may confer short-term effects on pain (SMD -0.68, 95%CI -1.03 to -0.34; mean difference (MD) 1.18 points (95% CI -1.78 to -0.59) and physical function (SMD -0.60, 95%CI -0.88 to -0.34; MD 12.95 (95%CI -20.05 to -5.86)) compared to placebo EPTs, based on very low-certainty evidence. No other EPTs (TENS, interferential, heat, shockwave, shortwave, ultrasound, EMG biofeedback, NMES) showed clinically significant effects compared to placebo/exercise, or exercise only.

Conclusions

Very low-certainty evidence supports laser therapy used adjunctively with exercise for short-term improvement in pain and function. No other EPTs demonstrated clinically meaningful effects.

One spinal manipulation session reduces local pain sensitivity but does not affect postural stability in individuals with chronic low back pain: a randomised, placebo-controlled trial

BACKGROUND

Clinical practice guidelines recommend spinal manipulation for patients with low back pain. However, the effects of spinal manipulation have contradictory findings compared to placebo intervention. Therefore, this study investigated the immediate effects of lumbar spinal manipulation on pressure pain threshold (PPT) and postural stability in people with chronic low back pain (cLBP). Second, we investigated the immediate effect of lumbar spinal manipulation on pain intensity and the interference of the participant beliefs about which treatment was received in the PPT, postural stability, and pain intensity.

METHODS

A two-arm, randomised, placebo-controlled, double-blind trial was performed. Eighty participants with nonspecific cLPB and a minimum score of 3 on the Numeric Pain Rating Scale received one session of lumbar spinal manipulation (n = 40) or simulated lumbar spinal manipulation (n = 40). Primary outcomes were local and remote PPTs and postural stability. Secondary outcomes were pain intensity and participant's perceived treatment allocation. Between-group mean differences and their 95% confidence intervals (CIs) estimated the treatment effect. One-way analysis of covariance (ANCOVA) was performed to assess whether beliefs about which treatment was received influenced the outcomes.

RESULTS

Participants had a mean (SD) age of 34.9 (10.5) years, and 50 (62.5%) were women. Right L5 [between-group mean difference = 0.55 (95%CI 0.19 to 0.90)], left L5 [between-group mean difference = 0.45 (95%CI 0.13 to 0.76)], right L1 [between-group mean difference = 0.41 (95%CI 0.05 to 0.78)], left L1 [between-group mean difference = 0.57 (95%CI 0.15 to 0.99)], left DT [between-group mean difference = 0.35 (95%CI 0.04 to 0.65)], and right LE [between-group mean difference = 0.34 (95%CI 0.08 to 0.60)] showed superior treatment effect in the spinal manipulation group than sham. Neither intervention altered postural stability. Self-reported pain intensity showed clinically significant decreases in both groups after the intervention. A higher proportion of participants in the spinal manipulation group achieved more than two points of pain relief (spinal manipulation = 90%; sham = 60%). The participants' perceived treatment allocation did not affect the outcomes.

CONCLUSION

One spinal manipulation session reduces lumbar pain sensitivity but does not affect postural stability compared to a sham session in individuals with cLPB. Self-reported pain intensity lowered in both groups and a higher proportion of participants in the spinal manipulation group reached clinically significant pain relief. The participant's belief in receiving the manipulation did not appear to have influenced the outcomes since the adjusted model revealed similar findings.

The challenge of pharmacotherapy for musculoskeletal pain: an overview of unmet needs

Musculoskeletal disorders are characterized by several impairments, including pain, affecting muscles, bones, joints and adjacent connective tissue, resulting in temporary or permanent functional limitations and disability. Musculoskeletal pain is particularly prevalent worldwide and greatly impacts the quality of life, social participation and economic burden. To date, several issues persist about the classification of musculoskeletal pain and its management strategies and resources. The treatment of musculoskeletal pain conditions is complex and often requires a multimodal approach, including pharmacological and non-pharmacological therapy that might be ineffective in many cases, resulting in poor patient satisfaction and controversial expectations about the potential benefits of available interventions. This manuscript provides an overview of unmet needs in managing musculoskeletal pain, particularly focusing on pharmacotherapeutic pitfalls in this context.

The importance of context (placebo effects) in conservative interventions for musculoskeletal pain: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND AND OBJECTIVE

Contextual effects (e.g. patient expectations) may play a role in treatment effectiveness. This study aimed to estimate the magnitude of contextual effects for conservative, non-pharmacological interventions for musculoskeletal pain conditions. A systematic review and meta-analysis of randomized controlled trials (RCTs) that compared placebo conservative non-pharmacological interventions to no treatment for musculoskeletal pain. The outcomes assessed included pain intensity, physical functioning, health-related quality of life, global rating of change, depression, anxiety and sleep at immediate, short-, medium- and/or long-term follow-up.

DATABASES AND DATA TREATMENT

MEDLINE, EMBASE, CINAHL, Web of Science Core Collection, CENTRAL and SPORTDiscus were searched from inception to September 2021. Trial registry searches, backward and forward citation tracking and searches for prior systematic reviews were completed. The Cochrane risk of bias 2 tool was implemented.

RESULTS

The study included 64 RCTs (N = 4314) out of 8898 records. For pain intensity, a mean difference of (MD: -5.32, 95% confidence interval (CI): -7.20, -3.44, N = 57 studies with 74 outcomes, GRADE: very low) was estimated for placebo interventions. A small effect in favour of the placebo interventions for physical function was estimated (SMD: -0.22, 95% CI: -0.35, -0.09; N = 37 with 48 outcomes, GRADE: very low). Similar results were found for a broad range of patient-reported outcomes. Meta-regression analyses did not explain heterogeneity among analyses.

CONCLUSION

The study found that the contextual effect of non-pharmacological conservative interventions for musculoskeletal conditions is likely to be small. However, given the known effect sizes of recommended evidence-based treatments for musculoskeletal conditions, it may still contribute an important component.

SIGNIFICANCE

Contextual effects of non-pharmacological conservative interventions for musculoskeletal conditions are likely to be small for a broad range of patient-reported outcomes (pain intensity, physical function, quality of life, global rating of change and depression). Contextual effects are unlikely, in isolation, to offer much clinical care. But these factors do have relevance in an overall treatment context as they provide almost 30% of the minimally clinically important difference.

The Nocebo Effect: A Bias in Clinical Practice-An Ethical Approach

BACKGROUND

The nocebo effect is often disregarded in medical practice and is certainly much less known than the placebo effect, although, in reality, both can influence therapeutic decision making and the quality of life of patients. However, the nocebo effect raises a number of issues not only of a practical nature related to clinical activity but also ethical dilemmas related to the observance of the patient's autonomy, nonmaleficence, or informed consent and the information on which it is based.

AREAS OF UNCERTAINTY

The ethical dilemmas raised by the nocebo effect revolve around how informed consent can be achieved, the accuracy and volume of information that is transmitted to the patient, and how to report negative side effects of therapeutic treatment.

DATA SOURCES

In September 2023, a narrative analysis of the literature was conducted using a combination of keywords such as nocebo, placebo, ethics, therapeutic relationship from PubMed, Scopus, Google Scholar, and so on, as well as from official documents developed at an international level (World Health Organization), for a period of 10 years (2012-2021).

RESULTS

Analyzing the articles that remarked upon the significant impact of ethics in nocebo research or in the therapeutic relationship, we can state that the existence of several relevant issues of interest have been detected regarding the ethical use of nocebo and its impact in research or in clinics and thus the need for proper knowledge and management of the impact of nocebo effects. The ethical paradox of obtaining informed consent with the 2 goals, first, the need for complete information and second, the preservation of the autonomy of the patient, respectively, that of "primum non-nocere" and of avoiding unnecessary harm by revealing probable adverse effects is a point of interest for numerous studies. The potential for a nocebo effect is present when we inform patients about the risks and benefits of treatment, there being a clear link between the moral and ethical duty to inform patients and the need to avoid situations that increase the nocebo impact on how the disease or the adverse effects of the treatment are perceived. Adapting information about the side effects of medicines should focus on ensuring a balance between transparency and caution, especially in patients with a high potential for nocebo effect.

CONCLUSIONS

The nocebo effect had for a long time been unknown or denied, although it can interfere with the results of the treatment used. As the nocebo phenomenon becomes increasingly known in medical practice, the clinical and ethical implications are identified by medical staff, and nocebo's adverse responses are no longer ignored.

An international consensus on gaps in mechanisms of forced-based manipulation research: findings from a nominal group technique

Force-Based Manipulation (FBM) including light touch, pressure, massage, mobilization, thrust manipulation, and needling techniques are utilized across several disciplines to provide clinical analgesia. These commonly used techniques demonstrate the ability to improve pain-related outcomes; however, mechanisms behind why analgesia occurs with these hands-on interventions has been understudied. Neurological, neuroimmune, biomechanical, neurovascular, neurotransmitter, and contextual factor interactions have been proposed to influence response; however, the specific relationships to clinical pain outcomes has not been well established. The purpose of this study was to identify gaps present within mechanism-based research as it relates to FBM. An international multidisciplinary nominal group technique (NGT) was performed and identified 37 proposed gaps across eight domains. Twenty-three of these gaps met consensus across domains supporting the complex multisystem mechanistic response to FBM. The strength of support for gaps within the biomechanical domain had less overall support than the others. Gaps assessing the influence of contextual factors had strong support as did those associating mechanisms with clinical outcomes (translational studies). The importance of literature investigating how FBM differs with individuals of different pain phenotypes (pain mechanism phenotypes and clinical phenotypes) was also presented aligning with other analgesic techniques trending toward patient-specific pain management (precision medicine) through the use of pain phenotyping.

IUPHAR review: Navigating the role of preclinical models in pain research

Chronic pain is a complex and challenging medical condition that affects millions of people worldwide. Understanding the underlying mechanisms of chronic pain is a key goal of preclinical pain research so that more effective treatment strategies can be developed. In this review, we explore nociception, pain, and the multifaceted factors that lead to chronic pain by focusing on preclinical models. We provide a detailed look into inflammatory and neuropathic pain models and discuss the most used animal models for studying the mechanisms behind these conditions. Additionally, we emphasize the vital role of these preclinical models in developing new pain-relief drugs, focusing on biologics and the therapeutic potential of NMDA and cannabinoid receptor antagonists. We also discuss the challenges of TRPV1 modulation for pain treatment, the clinical failures of neurokinin (NK)- 1 receptor antagonists, and the partial success story of Ziconotide to provide valuable lessons for preclinical pain models. Finally, we highlight the overall success and limitations of current treatments for chronic pain while providing critical insights into the development of more effective therapies to alleviate the burden of chronic pain.

Identifying priority gaps in contextual factors research and force-based manipulation. An international and interdisciplinary Delphi study

OBJECTIVE

To establish priority gaps related to contextual factors (CFs) research and force-based manipulation (FBM).

METHODS

A three-round Delphi following recommended guidelines for conducting and reporting Delphi studies (CREDES) involving international and interdisciplinary panelists with expertise in CFs and FBM. Round 1 was structured around two prompting questions created by the workgroup. Ranking of each priority gap was done by calculating composite scores for each theme generated. Consensus threshold was set with an agreement ≥75% among panelists. Median and interquartile range were calculated for each priority gap to provide the central tendency of responses. Wilcoxon rank-sum test was used to evaluate the consistency and stability of responses between rounds 2 and 3.

RESULTS

Forty-six panelists participated in all three rounds of the Delphi. Consensus was reached for 16 of 19 generated themes for priority gaps in CFs research and FBM. The ranking of each identified gap was computed and presented. Wilcoxon rank-sum test was non-significant (P > .05), demonstrating consistency and stability of results between rounds.

CONCLUSION

The result of this Delphi provides international and interdisciplinary consensus-based priority gaps in CFs research and FBM. The gaps identified can be used to generate future research inquiries involving CFs research and FBM.

The desire for side-effect information in pain treatment: an experimental analysis of contextual and individual difference factors

ABSTRACT

Informing patients about potential side effects of pain treatment is a requirement that protects patients and aids decision making, but it increases the likelihood of unwanted nocebo side effects. If patients do not desire all side-effect information, it may be possible to ethically reduce nocebo effects through authorized concealment of side effects, whereby patients and clinicians engage in shared decision-making to regulate the disclosure of side-effect information. Currently, there is no experimental data clarifying the factors that causally influence desire for side-effect information in pain treatment. In 2 cross-sectional, between-subjects scenario experiments (experiment 1 N = 498, experiment 2 N = 501), 18 to 79-year-old community adults learned about a lower back pain treatment, and potential side-effect severity, frequency, and duration were manipulated. Individual differences in information avoidance were also recorded. In both experiments, participants reported high desire for side-effect information, but the desire was reduced when side effects were described as less severe, less frequent, and participants scored high in information avoidance. Results were not moderated by participants' level of contact with the health care system, chronic health condition, or clinical pain history. Additional analyses indicated that low side-effect severity and frequency lessen desire for side-effect information because these variables reduce belief that side-effect information will be needed in the future and lower feelings of anticipated regret. The experiments identify situational and individual-difference factors that decrease the desire for side-effect information and provide evidence on when and for whom it may be useful for physicians to engage in shared medical decision-making with the goal of reducing nocebo side effects.

A qualitative study exploring the ritual-like activity and therapeutic relationship between Pilates teachers and clients with persistent low back pain

BACKGROUND AND PURPOSE

Pilates is a commonly recommended exercise modality for the management of persistent low back pain. Whilst guidelines recommend the use of exercise for low back pain, research suggests that no one exercise is superior, creating a question over the mechanism of effect. The patient-practitioner relationship may be important in managing low back pain; however, the relationship between Pilates teachers and clients is not well understood. The purpose of this study was to identify the components of the relationship between Pilates teachers and clients with persistent low back pain, explore key influences on the relationship, and ascertain the nature of the relationship.

METHOD

We conducted a qualitative, ethnographically-informed study at eight sites in the South of England, observing 24 Pilates sessions and interviewing 9 Pilates teachers and 10 clients with persistent low back pain. Fieldnotes and interview transcripts were analysed thematically.

RESULTS

The findings demonstrate a complex, multi-faceted interaction that occurs during Pilates sessions, grounded within certain health perceptions, and predicated on expectations of individuality, choice and expertise. A key finding reveals the perceived importance of mastery of prescribed movements with control and precision, in which clients particularly value the authority of the teacher in a directive learning environment.

CONCLUSION

We contend that the role of the Pilates teacher in this study facilitated the alleviation of clients' distress through the application of ritual-like Pilates activity. We conclude that the relationship between Pilates teachers and clients with persistent low back pain may be considered a therapeutic relationship.

How should uncertainty about upcoming painful procedures be communicated? An experimental study into highly uncertain pain predictions

OBJECTIVE

Uncertainty is unavoidable in the context of painful medical procedures. It is important to investigate the impact of different ways of communicating uncertainty on upcoming pain.

METHODS

In our exploratory study, healthy participants (n = 30) were repeatedly presented with three highly uncertain pain predictions communicated by a hypothetical doctor. A direct statement of high uncertainty ("I don't know") was compared to more indirect predictions (social prediction: "It varies widely among people"; range prediction: "… not painful at all to very highly painful"), followed by individually calibrated electrical stimuli of non-, moderately, or very highly painful intensity.

RESULTS

The direct expression of uncertainty led to the most intense pain sensation (for moderately painful stimuli only), lowest and most certain pain expectations, lowest trust in the hypothetical doctor, and lowest feeling of being well-informed, especially as compared to the social prediction. No differential effects on anxiety were observed.

CONCLUSIONS

Expressing high uncertainty indirectly, with reference to the common experiences of others, may be beneficial for optimizing pain experiences and enhancing patients' trust in a medical professional.

PRACTICE IMPLICATIONS

Our findings inform on how high uncertainty about upcoming pain may impact patient and health outcomes, pointing to some advantages of indirect communication.

Adding Brief Pain Science or Ergonomics Messages to Guideline Advice Did Not Increase Feelings of Reassurance in People With Acute Low Back Pain: A Randomized Experiment

OBJECTIVE: To investigate the effects of adding pain science or ergonomics messages to guideline advice on feelings of reassurance and management intentions among people with acute low back pain (LBP). DESIGN: Three-arm parallel-group randomized experiment. METHODS: We recruited people with acute LBP (pain for ≤6 weeks) to participate in an online experiment. Participants were randomized at a 1:1:1 ratio to one of three groups: guideline advice alone or guideline advice with the addition of brief pain science or ergonomics messages. The intervention was delivered via prerecorded videos in all 3 groups. Coprimary outcomes were reassurance that (1) no serious condition is causing LBP and (2) continuing with daily activities is safe. Secondary outcomes were perceived risk of developing chronic pain, management intentions (bed rest, see a health professional, see a specialist, and imaging), credibility, and relevance of the advice in addressing the participant's concerns. RESULTS: Two thousand two hundred ninety-seven responses (99.3% of 2,313 randomized) were analyzed. Adding brief pain science or ergonomics messages to guideline advice did not change reassurance that LBP was not caused by serious disease. The addition of ergonomics advice provided worse reassurance that it is safe to continue with daily activities compared to guideline advice (mean difference [MD], -0.33; 95% CI: 0.13, 0.53). There was no difference between groups on management intentions. CONCLUSION: Adding pain science or ergonomics messages to guideline advice did not increase reassurance or change management intentions in people with acute LBP. Ergonomics messages may lead to reduced feelings of reassurance. J Orthop Sports Phys Ther 2023;53(12)1-11. Epub 26 September 2023. doi:10.2519/jospt.2023.12090.

The biopsychosocial model is lost in translation: from misrepresentation to an enactive modernization

INTRODUCTION

There are increasing recommendations to use the biopsychosocial model (BPSM) as a guide for musculoskeletal research and practice. However, there is a wide range of interpretations and applications of the model, many of which deviate from George Engel's original BPSM. These deviations have led to confusion and suboptimal patient care.

OBJECTIVES

1) To review Engel's original work; 2) outline prominent BPSM interpretations and misapplications in research and practice; and 3) present an "enactive" modernization of the BPSM.

METHODS

Critical narrative review in the context of musculoskeletal pain.

RESULTS

The BPSM has been biomedicalized, fragmented, and used in reductionist ways. Two useful versions of the BPSM have been running mostly in parallel, rarely converging. The first version is a "humanistic" interpretation based on person- and relationship-centredness. The second version is a "causation" interpretation focused on multifactorial contributors to illness and health. Recently, authors have argued that a modern enactive approach to the BPSM can accommodate both interpretations.

CONCLUSION

The BPSM is often conceptualized in narrow ways and only partially implemented in clinical care. We outline how an "enactive-BPS approach" to musculoskeletal care aligns with Engel's vision yet addresses theoretical limitations and may mitigate misapplications.

The development of the Therapeutic Group Context Questionnaire: Reliability and validity measures based on telehealth Group-based Pain Management Programs

INTRODUCTION

In 2016, the Centers for Disease Control and Prevention analyzed the National Health Interview Survey data and found that the occurrence of chronic pain and high-impact chronic pain in the USA was 20.4% and 8%, respectively. Group-based Pain Management Programs have been viewed as significant treatments aiding patients with self-management of chronic pain. The onset of coronavirus disease 2019 (COVID-19) at the beginning of 2020, widely eliminated the in-person Group-based Pain Management Programs. The exploration of therapeutic contextual factors such as the therapeutic alliance and group dynamics in telehealth Group-based Pain Management Programs appears warranted for which reason the Therapeutic Group Context Questionnaire was developed.

METHODS

The therapeutic alliance and group dynamics items in the Therapeutic Group Context Questionnaire were developed from an extensive literature review and underwent examination of content validity, internal consistency, reliability, and validity through telehealth Group-based Pain Management Programs.

RESULTS

Content validity of the Therapeutic Group Context Questionnaire was established in five separate stages and the psychometrics of the Therapeutic Group Context Questionnaire was found to be very good with high internal consistency and reliability (r = 0.85-0.97) and the ability of the Therapeutic Group Context Questionnaire to differentiate between high and low scorers on the SF-36 emotional well-being measure.

DISCUSSION

The examination of therapeutic contextual factors via telehealth Group-based Pain Management Programs using the Therapeutic Group Context Questionnaire appears possible in view of the very good psychometric properties described above. Investigation of therapeutic contextual factors through the Therapeutic Group Context Questionnaire may provide greater insight into the role that these factors may have in telehealth programs and their impact on pain outcomes. Future investigation of the Therapeutic Group Context Questionnaire in non-telehealth Group-based Pain Management Programs, as well as, other disorders being addressed via telehealth appears warranted.

The relationship of perceived empathy with levels of pain intensity and incapability among patients visiting a musculoskeletal specialist

BACKGROUND

People that have more intense symptoms and greater incapability might have less rapport with the clinicians that care for them.

OBJECTIVE

This study tested the hypothesis that perceived clinician empathy is related to pain intensity and magnitude of incapability among people seeing a musculoskeletal specialist.

PATIENT INVOLVEMENT

After a consult with a musculoskeletal specialist, 211 adult patients completed a survey recording demographics, and measures of pain intensity, incapability, and perceived clinician empathy.

RESULTS

Higher perceived empathy was associated with being in a committed relationship and, to a modest degree (r = -0.16) lower pain intensity in bivariate and multivariable analyses.

DISCUSSION

People experiencing greater pain may be slightly less likely to perceive the clinician as empathetic.

PRACTICAL VALUE

Study of the relationship between the patient's experience of care and patient and clinician personal factors can inform efforts to improve patient experience. Advances may depend on experience measures with more normal distributions and less ceiling effect.

Effect of stress on contextual pain sensitivity in the preoperative period- A proof of concept study

Background and Aims

The importance of non-noxious contextual inputs in the interplay of pain with neurophysiologic and behavioral factors is gaining recognition. Stress of impending surgery can act as a negative context, leading to a decrease in pain threshold in patients. This study was conducted to assess the influence of stress conferred by the imminent and other contextual inputs such as anxiety, socioeconomic status, prior painful experience, and the effect of gender on modulation of pain perception in patients undergoing elective surgery.

Material and Methods

In total, 120 patients aged between 18 and 60 years of either gender posted for elective gastrointestinal surgery under general anesthesia were recruited. Data were collected on preoperative anxiety level, socioeconomic status, education, and any prior painful experience. A pressure algometer was used to measure the pressure pain thresholds and pain tolerance on the day before surgery and on the morning of surgery in the preoperative suite.

Results

There was a statistically significant decrease in both pain threshold (P < 0.0001) and pain tolerance in the immediate preoperative period in comparison to the baseline readings taken the day before surgery (P = 0.048). The magnitude of change in pain scalars was greater in females (P < 0.001), those with a high anxiety score, and a history of severe painful experience in the past.

Conclusion

Preoperative surgical stress lowers the pain threshold and pain tolerance. Contextual modulation of pain by factors such as anxiety and memory of prior painful experience, especially in the female gender, could influence postoperative patient outcomes and warrants further research.

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.

Using contextual factors to elicit placebo and nocebo effects: An online survey of healthcare providers' practice

Contextual factor use by healthcare professionals has been studied mainly among nurses and physiotherapists. Preliminary results show that healthcare professionals use contextual factors without specifically labelling them as such. The main objective of this study was to evaluate knowledge and explore voluntary contextual factor use among various healthcare professions. The results aim to facilitate hypothesis-generation, to better position further research to explain and characterise contextual factor use. We conducted a web-based questionnaire cross-sectional observational study on a non-probabilistic convenience sample. Face and content validity were tested through cognitive interviews. Data were analysed descriptively. The target population was the main healthcare profession, or final year students, defined by the French public health law. The countries of distribution of the questionnaire were the French-speaking European countries. Among our 1236 participants, use of contextual factors was widespread. Those relating to the therapeutic relationship (e.g., communication) and patient characteristics (e.g., past experiences) were reportedly the most used. Meanwhile, contextual factors related to the healthcare providers' characteristics and their own beliefs were reported as less used. Despite high variability, respondents suggested contextual effects contribute to approximately half of the overall effect in healthcare and were perceived as more effective on children and elderly adults. Conceptual variations that exist in the literature are also present in the way healthcare providers consider contextual effects. Interestingly, there seems to be common ground between how physiotherapists, nurses and physicians use different contextual factors. Finally, in the present study we also observed that while there are similarities across usage, there is lack of both an epistemological and ethical consensus among healthcare providers with respect to contextual factors.

Factors Associated with Treatment Outcome Satisfaction Six Months after Upper Blepharoplasty: A Large Cohort Study

Background

Upper blepharoplasty is the most popular facial cosmetic surgery. Although there are a variety of reasons to undergo this procedure, all patients expect an optimal cosmetic result. However, little is known about the factors that influence satisfaction with treatment outcome.

Objectives

We assessed to what extent patient characteristics, clinician-rated and postsurgical outcome measures, and patient-reported satisfaction with facial appearance and quality-of-life are associated with patient-reported satisfaction with treatment outcome after a primary upper blepharoplasty.

Methods

This study was performed in 583 patients with an upper blepharoplasty between 2016 and 2021. The primary outcome was satisfaction with treatment outcome 6 months postoperatively using the FACE-Q. Determinants were baseline patient characteristics (demographics), preoperative and postoperative clinician-rated and surgical outcome measures, and preoperative and postoperative FACE-Q appearance and quality-of-life scales. Hierarchical linear regression analysis was used to determine how much of the variance in satisfaction with outcome could be explained by these groups of determinants.

Results

A total of 63% of the variance could be explained by the five groups of determinants of which 8% was explained by the baseline patient characteristics and clinician-rated and patient-reported outcomes together, another 8% by the postoperative clinician-rated outcomes, and the remaining 47% by the postoperative patient-reported outcomes.

Conclusions

Patient characteristics, clinician-rated outcome measures, and baseline FACE-Q appearance and quality-of-life scores were of limited value in explaining satisfaction with treatment outcome. However, the postoperative FACE-Q appearance scale and the decision to undergo a blepharoplasty were strongly associated with satisfaction with treatment outcome.

Exploring Communication Practices in Italian Physiotherapy: Knowledge and Use of Effective Communication Strategies-A National Descriptive Study

This study aimed to investigate the knowledge and use of effective communication strategies among Italian physiotherapists. We utilized a questionnaire consisting of 19 questions to collect data on the knowledge and use of effective communication strategies among Italian physiotherapists. The results revealed that only 35.8% of the respondents reported being aware of communication strategies related to physiotherapy, with their first exposure occurring during their three-year degree. Despite the majority of respondents agreeing that communication is an effective strategy for improving patient adherence, only about half reported making moderate use of open-ended questions and metaphors during treatment sessions. Furthermore, more than half of the respondents reported being unaware of Motivational Interviewing. The results of this study found that there is a consensus among Italian physiotherapists about the importance of effective communication in clinical practice, though the knowledge and application of some communication strategies remain limited. These findings suggest that there is room for improvement in the training and education of physiotherapists in Italy, with a need for greater emphasis on communication strategies in the university educational curriculum, starting from the bachelor's degree.

Using medical storytelling to communicate problems and solutions in the low back pain conundrum: an evidence-based tale of twins

OBJECTIVES

Low back pain (LBP) is the number one cause of disability world-wide. It is also the most expensive area in healthcare. Patient-centered innovations are needed. This paper uses medical storytelling to illustrate the common problems that often lead to unnecessary suffering for patients, and costs to society. We present innovative solutions, including narrative interventions.

METHODS

We use medical storytelling to present a scenario in which hypothetical twin patients with identical LBP episodes enter the healthcare system, with one twin managed in an appropriate manner, and the other inappropriately.

RESULTS

One twin becomes a chronic LBP sufferer, while the other experiences quick resolution, despite identical conditions. Recommendations are made to de-implement inappropriate action and to implement a more productive approach.

CONCLUSIONS

Many patients with LBP descend into chronic pain. This is rarely inevitable based on clinical factors. Much of chronic LBP results from how the condition is handled within the healthcare system. Medical narrative may be one innovation to illustrate the problem of current LBP management, recommend solutions and foster changes in clinical behavior.

PRACTICAL IMPLICATIONS

The starkly different outcomes for each identical twin are illustrated. Recommendations are made for reframing the situation to de-implement the inappropriate and to implement a more appropriate approach.

Patient complaints about communication in cancer care settings: Hidden between the lines

OBJECTIVES

To investigate patient complaints in cancer care settings reported to patient advisory committees (PACs) and describe the frequency and content of communication failures across all reports.

METHODS

Content analysis, with a summative approach, was applied to cancer care complaints (2016-2020) by 692 patients to PACs in one Swedish healthcare region.

RESULTS

More than half the patients reported communication failures. Patients reported not receiving proper information, not being listened to, and being treated disrespectfully or impersonally. Communication failures occurred in different stages of the patients' cancer care, from diagnostic workup to end-of-life. Compared with the results of the PACs, communication failures were underreported, and were often combined with complaints in other categories.

CONCLUSIONS

Communication failures are hidden "between the lines" and do not appear clearly in existing reporting systems. Healthcare must utilize the knowledge conveyed by patient complaints and create conditions and environments that support healthcare providers in delivering person-centered care.

PRACTICE IMPLICATION

A summary picture of patients' complaints in Swedish cancer care is provided. These results could be used to further improve the patient complaint system. Above all, the results could serve as a "wake-up call" about the importance of communication and a valuable resource in improving cancer care.

The Importance of the Treatment Rationale for Pain in Animal-Assisted Interventions: A Randomized Controlled Trial in Healthy Participants

Animal-assisted interventions (AAIs) is a promising treatment approach for pain, but possible mechanisms still need to be elucidated. This study set out to investigate the analgesic effects of an animal provided with a treatment rationale in a randomized controlled trial employing a standardized experimental heat-pain paradigm. We randomly assigned 128 healthy participants to: dog treatment (DT), placebo treatment (PT), dog and placebo treatment (DPT), and no treatment (NT). Primary outcomes were heat-pain tolerance and the corresponding self-reported ratings of pain unpleasantness and intensity. Results revealed no differences in heat-pain tolerance between the conditions. However, participants in the DT condition experienced heat-pain as significantly less unpleasant at the limit of their tolerance compared to participants in the NT condition (estimate = -0.96, CI = -1.58 to 0.34, P = .010). Participants in the DT condition also showed lower ratings of pain intensity at the limit of their tolerance compared to participants in the NT condition (estimate = -0.44, CI = -0.89 to 0.02, P = .060). This study indicates that a dog has analgesic effects on pain perception when integrated into the treatment rationale. We assume that providing a treatment rationale regarding the animal is important in AAIs for pain. PERSPECTIVE: This study shows that the presence of an animal is not sufficient for animal-assisted interventions (AAIs) to have an analgesic effect on pain unless they are provided with a treatment rationale. This could imply that not only the animal but also contextual factors are important in AAIs. TRIAL REGISTRATION: Clinical Trials NCT04361968.

Modernizing patient-centered manual therapy: Findings from a Delphi study on orthopaedic manual therapy application

BACKGROUND

Recent literature challenges the process by which orthopaedic manual therapy (OMT) has traditionally been applied. Progressive understanding of the complexities surrounding OMT analgesia and the decreased reliance on technique specific characteristics in determining treatment effectiveness promotes an update to training paradigms related to OMT.

OBJECTIVES

The purpose of this Delphi study was to establish consensus on what trainees should be focusing on when demonstrating OMT techniques and how candidates for OMT should be identified.

DESIGN

An international three-round Delphi study following recommended guidelines for conducting and reporting of Delphi studies (CREDES) was performed.

METHODS

One-hundred sixty-four expert manual therapy educators were identified for participation across four countries. Participants were asked to provide what concepts trainees should be focusing on when demonstrating OMT techniques and how candidates for OMT should be identified. Twenty-one themes were identified for each question.

RESULTS

Twenty-eight participants completed all three rounds of the Delphi. Consensus was reached on nineteen themes and eighteen themes respectively. Results from this Delphi stress patient-centered care within a biopsychosocial pain management model. Representation across all pillars of evidence-based practice were represented. Themes reaching consensus within this study favored the importance of neurophysiological, psychological, and biomechanical principles.

CONCLUSION

This Delphi presents consensus-based recommendations for what manual therapy trainees should focus on when demonstrating OMT techniques and on how candidates for OMT should be identified. These findings in collaboration with previous consensus recommendations on concepts to focus on within OMT education promote restructuring of OMT curriculum to evidence-based patient-centered care models.

Protocol of identical exercise programs with and without specific breathing techniques for the treatment of chronic non-specific low back pain: randomized feasibility trial with two-month follow-up

BACKGROUND

Chronic low back pain (CLBP) is a leading cause of disability globally. Exercise therapies are one of the commonly prescribed treatment options for CLBP. The specific exercise therapies for CLBP most commonly target movement dysfunction, but seldom brain-based pain modulation. Exercise therapies with specific breathing techniques (SBTs) have been shown to influence and enhance brain-based structural and functional pain modulation.

AIMS AND OBJECTIVES

To assess the feasibility of the SBTs protocol, eligibility criteria, randomization, and dropout rates. To quantify the changes in patient outcome measures and choose the most relevant measure for larger-scale study. To quantify self-adherence levels to home exercise and monitor and record possible pain medication and other treatment modality usage, and adverse events during exercise.

DESIGN

A parallel randomised analyst-blinded feasibility trial with two-month follow-up.

OUTCOME MEASURES

Feasibility related to aims and objectives. Multiple pain- and health-related patient-reported outcome measures of pain intensity, disability, central sensitization, anxiety, kinesiophobia, catastrophising, self-efficacy, sleep quality, quality of life, and health and well-being status. Exercise adherence, pain medication and other treatment modality usage, and possible adverse events related to exercises will be monitored and recorded.

METHODS

Thirty participants will be randomized to movement control exercise with SBTs (15 subjects in experimental group) or movement control exercise without SBTs (15 subjects in control group) in private chiropractic practice setting with two-month follow-up. Trial registration number; NCT05268822.

DISCUSSION

The clinical difference in effectiveness between practically identical exercise programs in uniform study settings with or without SBTs has not been studied before. This study aims to inform feasibility and help determine whether progression to a full-scale trial is worthwhile.

Negative language use of the physiotherapist in low back pain education impacts anxiety and illness beliefs: A randomised controlled trial in healthy respondents

OBJECTIVE

This study aimed to determine the effect of physiotherapists' negative language use on nocebo effects of state anxiety and illness beliefs.

METHODS

A web-based randomised controlled trial included adults without recent musculoskeletal pain. The intervention was a short educational video about low back pain using negative language (nocebo condition: n = 87) versus a video using neutral or positive language (control condition: n = 82). State anxiety was assessed using the State-Trait Anxiety Inventory. Illness beliefs were assessed using the Illness Perception Questionnaire.

RESULTS

Nocebo and control groups differed in outcome measures (MANOVA Pillai's trace = 0.22, F = 4.98; df = (9,159), p < 0.001). Post-hoc analyses showed a medium to large effect for the nocebo condition on anxiety (d = 0.71, 95% CI 0.4 -1.0). The nocebo group also had higher scores in three illness beliefs: beliefs on timeline (d = 0.45, 95% CI 0.14 - 0.75), treatment control (d = 0.43, 95% CI 0.12 - 0.74) and concern (d = 0.47, 95% CI 0.16 - 0.78).

CONCLUSION

Physiotherapists' use of negative language contributes directly to a higher state anxiety and illness beliefs that can trigger the nocebo effects in the recipient PRACTICE IMPLICATIONS: Negative language use should be avoided.

Effect of Regular Electrotherapy on Spinal Flexibility and Pain Sensitivity in Patients with Chronic Non-Specific Neck Pain and Low Back Pain: A Randomized Controlled Double-Blinded Pilot Trial

Background and Objectives: Chronic neck pain and low back pain are common conditions in high-income countries leading to social and medical problems such as invalidity and decreased quality of life. The aim of this study was to investigate the effect of supra-threshold electrotherapy on pain level, subjective feeling of disability, and spinal mobility in patients with chronic pain in the spinal cord. Materials and Methods: 11 men and 24 women with a mean age of 49 years were randomly divided into three groups: group 1, "therapy": supra-threshold electrotherapy was applied on the whole back after electrical calibration; group 2, "control": electrical calibration without successive electrotherapy; group 3, "control of control": no stimulation. Sessions were performed once a week and six times in total, each lasting 30 min. The numeric pain rating scale (NRS), cervical and lumbar range of motion (ROM), as well as disability in daily live were investigated before and after the sessions using questionnaires (Neck Disability Index, Roland Morris Questionnaire, Short-form Mc Gill Pain Questionnaire (SF-MPQ)). Results: Spinal mobility improved significantly in the lumbar anteflexion (baseline mean, 20.34 ± SD 1.46; post session mean, 21.43 ± SD 1.95; p = 0.003) and retroflexion (baseline mean, 13.68 ± SD 1.46; post session mean, 12.05 ± SD 1.37; p = 0.006) in the group receiving electrotherapy. Pain levels measured by the NRS and disability-questionnaire scores did not differ significantly before and after treatment in any of the groups. Conclusions: Our data indicate that regular supra-threshold electrotherapy for six times has a positive effect on lumbar flexibility in chronic neck pain and low back pain patients, whereas pain sensation or subjective feeling of disability remained unchanged.

Investigating the hypoalgesic effects of spinal manipulative therapy using hidden pain conditioning and positive expectation in patients with chronic low back pain: protocol for a randomised controlled trial

INTRODUCTION

Placebo effects are responses capable of modulating pain and influencing treatment response. Two mechanisms are commonly related to placebo effects: expectations and conditioning. However, the research in this field is focused on laboratory studies with healthy participants. This study aims to identify whether a conditioning procedure with positive induced expectations about spinal manipulative therapy (SMT) will result in greater hypoalgesic effects in adults with chronic low back pain (CLBP) in a clinical trial design.

METHODS AND ANALYSIS

This trial will enrol 264 patients with non-specific CLBP, aged 18-60 years. Patients will undergo a calibration test to determine the thermal pain threshold for the hidden pain conditioning procedure. Afterward, they will be randomised to one of the three groups: hidden pain conditioning with positive induced expectations-group one (G1); positive expectations-group two (G2) and neutral expectations-group three (G3). Patients will receive instructions to manipulate the expectations. The pretreatment heat pain test will be performed before the SMT and after the intervention patients will undergo again the heat pain intensity test. However, only patients in G1 will receive hidden pain conditioning to reinforce the association between SMT and pain intensity reduction. All patients will undergo five sessions of SMT. The outcomes will be assessed immediately after the last session and at the 6 weeks and 3-month follow-ups. All statistical analyses will be conducted following intention-to-treat principles, and the treatment effects will be determined with linear mixed models.

ETHICS AND DISSEMINATION

The Federal University of São Carlos approved this research (Process n° 52359521.1.0000.5504). All participants will give written informed consent. Dissemination of the results will include publications in peer-reviewed journals and presentations at conferences. If positive expectations and classical conditioning improve outcomes, it may support the administration of such intervention.

TRIAL REGISTRATION NUMBER

NCT05202704.

Musculoskeletal practitioners' perceptions of contextual factors that may influence chronic low back pain outcomes: a modified Delphi study

BACKGROUND

Optimal shaping of contextual factors (CFs) during clinical encounters may be associated with analgesic responses in treatments for musculoskeletal pain. These CFs (i.e., the patient-practitioner relationship, patient's and practitioner's beliefs/characteristics, treatment characteristics, and environment) have not been widely evaluated by musculoskeletal practitioners. Understanding their views has the potential to improve treatment quality and effectiveness. Drawing on a panel of United Kingdom practitioners' expertise, this study aimed to investigate their perceptions of CFs during the management of patients presenting with chronic low back pain (LBP).

METHODS

A modified two-round online Delphi-consensus survey was conducted to measure the extent of panel agreement regarding the perceived acceptability and influence of five main types of CFs during clinical management of patients with chronic LBP. Qualified musculoskeletal practitioners in the United Kingdom providing regular treatment for patients with chronic LBP were invited to take part.

RESULTS

The successive Delphi rounds included 39 and 23 panellists with an average of 19.9 and 21.3 years of clinical experience respectively. The panel demonstrated a high degree of consensus regarding approaches to enhance the patient-practitioner relationship (18/19 statements); leverage their own characteristics/beliefs (10/11 statements); modify the patient's beliefs and consider patient's characteristics (21/25 statements) to influence patient outcomes during chronic LBP rehabilitation. There was a lower degree of consensus regarding the influence and use of approaches related to the treatment characteristics (6/12 statements) and treatment environment (3/7 statements), and these CFs were viewed as the least important. The patient-practitioner relationship was rated as the most important CF, although the panel were not entirely confident in managing a range of patients' cognitive and emotional needs.

CONCLUSION

This Delphi study provides initial insights regarding a panel of musculoskeletal practitioners' attitudes towards CFs during chronic LBP rehabilitation in the United Kingdom. All five CF domains were perceived as capable of influencing patient outcomes, with the patient-practitioner relationship being perceived as the most important CF during routine clinical practice. Musculoskeletal practitioners may require further training to enhance their proficiency and confidence in applying essential psychosocial skills to address the complex needs of patients with chronic LBP.

Improving Adherence to a Home Rehabilitation Plan for Chronic Neck Pain through Immersive Virtual Reality: A Case Report

Idiopathic chronic neck pain is a highly disabling musculoskeletal condition. Immersive virtual reality shows a promising efficacy in the treatment of chronic cervical pain through the mechanism of distraction from the pain. This case report describes the management of C.F., a fifty-seven-year-old woman, who suffered from neck pain for fifteen months. She had already undergone a cycle of physiotherapy treatments including education, manual therapy, and exercises, following international guidelines. The patient's poor compliance did not allow adherence to the exercise's prescription. Home exercise training through virtual reality was therefore proposed to the patient to improve her adherence to the treatment plan. The personalization of the treatment allowed the patient to resolve in a short time period her problem and return to live with her family peacefully.

Education-Enhanced Conventional Care versus Conventional Care Alone for Temporomandibular Disorders: A Randomized Controlled Trial

The objective of this study was to determine the effect of enhancing conventional care for people with chronic painful temporomandibular disorders (TMD) with an individualised contemporary pain science education (PSE) intervention. In this randomized controlled trial, a consecutive sample of 148 participants (18-55 years of age) was randomized into 2 groups: PSE-enhanced conventional care or Conventional care alone. Conventional care involved a 6-week, 12-session manual therapy and exercise program. The PSE enhancement involved 2 sessions of modern PSE, undertaken in the first 2 treatment sessions. Primary outcomes were pain intensity, assessed with a numeric pain rating scale, and disability, assessed with the craniofacial pain and disability inventory, post-treatment. Linear mixed model analyses were used to investigate between-group differences over time. There was a statistically and clinically meaningful effect of PSE enhancement on disability (Mean Difference = 6.1, 95% CI: 3.3-8.8), but not on pain intensity, post-treatment. Secondary analyses suggested clinically meaningful benefit of PSE enhancement on pain and disability ratings at 10-week and 18-week follow-ups, raising the possibility that preceding conventional care with a PSE intervention may result in long-term benefits. PERSPECTIVE: The addition of modern Pain Science Education (PSE) intervention improved disability for people with chronic TMD receiving manual therapy and exercise, but not pain. A mean difference in pain and disability favoring the PSE group at the 10- and 18-week follow-ups, respectively, suggests that PSE addition resulted in longer-lasting effects. Trial registration: NCT03926767. Registered on April 29, 2019. https://clinicaltrials.gov/ct2/show/NCT03926767.

Injury, illness, and emotion: A review of the motivational continuum from trauma through recovery from an ecological perspective

Image 1.

[The use of a fixed combination of diclofenac and orphenadrine in the treatment of acute pain syndrome in patients with discogenic lumbosacral radiculopathy and lumboischialgia]

Acute pain syndromes caused by discogenic lumbosacral radiculopathy and lumboischialgia are not uncommon in clinical practice and characterized by a high risk of becoming chronic. The pathogenetic aspects, features of the clinical picture, existing approaches to conservative treatment of these conditions are analyzed in this paper. Data on the efficacy and safety of a fixed combination of diclofenac and orphenadrine (Neodolpasse) use in the treatment of vertebrogenic pain syndromes based on the NEODOLEX study results are presented, and the authors' own clinical observations are given. Possible reasons for the high efficacy of Neodolpasse in patients with discogenic radiculopathies and nonspecific back and neck pain are discussed.

Historical Osteopathic Principles and Practices in Contemporary Care: An Anthropological Perspective to Foster Evidence-Informed and Culturally Sensitive Patient-Centered Care: A Commentary

Historical osteopathic principles and practices (OPP)-considering the patient as a dynamic interaction of the body, mind, and spirit and incorporating the body's self-healing ability into care-are inherited from traditional/complementary and alternative (CAM) principles. Both concepts are familiar to contemporary osteopathic practitioners, but their incorporation into healthcare for evidence-informed, patient-centered care (PCC) remains unclear. Further, a polarity exists in the osteopathic profession between a 'traditional-minded' group following historical OPP despite evidence against those models and an 'evidence-minded' group following the current available evidence for common patient complaints. By shifting professional practices towards evidence-based practices for manual therapy in line with the Western dominant biomedical paradigm, the latter group is challenging the osteopathic professional identity. To alleviate this polarity, we would like to refocus on patient values and expectations, highlighting cultural diversity from an anthropological perspective. Increasing an awareness of diverse sociocultural health assumptions may foster culturally sensitive PCC, especially when including non-Western sociocultural belief systems of health into that person-centered care. Therefore, the current medical anthropological perspective on the legacy of traditional/CAM principles in historical OPP is offered to advance the osteopathic profession by promoting ethical, culturally sensitive, and evidence-informed PCC in a Western secular environment. Such inclusive approaches are likely to meet patients' values and expectations, whether informed by Western or non-Western sociocultural beliefs, and improve their satisfaction and clinical outcomes.

Personalised exercise therapy and self-management support for people with multimorbidity: Development of the MOBILIZE intervention

BACKGROUND

To our knowledge, there is no intervention which includes personalised exercise therapy and self-management support for people with multimorbidity, although these interventions may be as effective as for people with single chronic conditions. Therefore, we developed a novel intervention, including personalised exercise therapy and self-management support for people with multimorbidity.

METHODS

We followed the Medical Research Council framework and conducted one scoping review, five systematic reviews, two registry-based studies, one qualitative interview study and a mixed-methods feasibility study. Following an iterative approach, together with feedback from people with multimorbidity and relevant stakeholders, we developed the MOBILIZE intervention.

RESULTS

The intervention included 24 (60 minutes) sessions of personalised exercise therapy and 24 (30 minutes) sessions of self-management support twice a week for 12 weeks, delivered in small groups by specifically trained physiotherapists. The intervention targets physiological, psychosocial, behavioural, and contextual factors to improve health-related quality of life and physical function in people living with multimorbidity.

CONCLUSIONS

We developed a personalised exercise therapy and self-management support programme for people with multimorbidity. The intervention will be tested for its safety and effectiveness in a randomised controlled trial.

Complexity theory in the management of patients with musculoskeletal pain

Nonlinear systems are not susceptible to research with a reductionist approach. In this sense, the complexity theory provides an alternative approach to quantify the importance of contextual factors in patients with musculoskeletal pain. The use of positive (placebo) or negative (nocebo) contextual factors in the therapeutic setting could largely account for the non-specific component of treatment efficacy, directly affecting the quality of patients’ health-related outcomes (e.g., pain, disability, or satisfaction). In recent years, there has been a better understanding of the effects of contextual factors. However, the knowledge and awareness of them is limited and heterogeneous among physical therapists, reducing their translational value in the field of physiotherapy. The purpose of this essay is to describe the management of patients with musculoskeletal pain from the complexity theory perspective.

Normal saline injection produces a therapeutic effect in patients with plantar fasciitis: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Injectable therapies have been increasingly investigated to treat plantar fasciitis in randomized controlled trials (RCT) where normal saline injections are frequently used as placebo. The purpose was to quantify the effect of saline injections and compared against available minimal clinically important difference (MCID) criteria specific for plantar fasciitis to assess if changes were clinically meaningful.

METHODS

RCT including a placebo group (normal saline) and reporting changes in pain and functional outcomes in plantar fasciitis were identified through a search in MEDLINE, Embase, Web of Science, and Scopus to February 2022. PRISMA guidelines and a registered protocol (PROSPERO: CRD42020214035) were followed to conduct the study.

RESULTS

Pooled analysis of 13 RCT (379 subjects) included for analysis revealed a significant improvement on pain (P < .00001) and functional scores (P < .00001) after normal saline injections. These changes exceeded the established MCID criteria.

CONCLUSIONS

Normal saline injections in plantar fasciitis showed a therapeutic effect with statistically and clinically meaningful improvement when administered in the setting of an RCT for up to 12 months. The control of potential confounders influencing the effect of saline injections is required for future research.

Gentle Touch Therapy, Pain Relief and Neuroplasticity at Baseline in Fibromyalgia Syndrome: A Randomized, Multicenter Trial with Six-Month Follow-Up

Background: Fibromyalgia (FM) is considered a stress-related disorder characterized mainly by chronic widespread pain. Its pathogenesis is unknown, but cumulative evidence points at dysfunctional transmitter systems and inflammatory biomarkers that may underlie the major symptoms of the condition. This study aimed to evaluate pain scores (primary outcome), quality of life, inflammatory biomarkers and neurotransmitter systems in women with FM (secondary outcomes) subjected to gentle touch therapy (GTT) or placebo. Methods: A total of 64 female patients with FM were randomly assigned to two groups, namely GTT (n = 32) or Placebo (n = 32). Clinical assessments were conducted at baseline and post-intervention with six-month follow-up. We measured serum catecholamines (dopamine), indolamines and intermediary metabolites (serotonin or 5-hydroxyindolacetic acid (5-HIAA)), as well as tetrahydrobiopterin (BH4), which is a cofactor for the synthesis of neurotransmitters and inflammatory biomarkers in women with FM. A group of healthy individuals with no intervention (control group) was used to compare biochemical measurements. Intervention effects were analyzed using repeated measures (RM) two-way ANOVA followed by Bonferroni post hoc test and mixed ANCOVA model with intention to treat. Results: Compared to placebo, the GTT group presented lower pain scores and brain-derived neurotrophic factor (BDNF) levels without altering the quality of life of women with FM. Changes in BDNF had a mediating role in pain. Higher baseline serum BDNF and 5-HIAA or those with a history of anxiety disorder showed a higher reduction in pain scores across time. However, women with higher serum dopamine levels at baseline showed a lower effect of the intervention across the observation period revealed by an ANCOVA mixed model. Conclusions: In conclusion, lower pain scores were observed in the GTT group compared to the placebo group without altering the quality of life in women with FM. Reductions in BDNF levels could be a mechanism of FM pain status improvement. In this sense, the present study encourages the use of these GTT techniques as an integrative and complementary treatment of FM.

Looking at Both Sides of the Coin: Addressing Rupture of the Therapeutic Relationship in Musculoskeletal Physical Therapy/Physiotherapy

As physical therapists, we may have all experienced tense moments in our therapeutic relationships with patients. Whether small or large, implicit or explicit, relational breakdowns are a normal part of human interactions. Within the clinical encounter, these tensions are called "ruptures." In psychotherapy, ruptures have been associated with increased dropout rates and poor clinical outcomes. To increase the likelihood that physical therapists establish, maintain, and strengthen therapeutic relationships with their patients, recognizing and repairing ruptures would seem logical. However, we contend that relational tensions, although inevitable, are most often avoided by physical therapists, potentially to the peril of the therapeutic relationship. A responsive approach that involves adjusting our mind-set, being aware, and taking appropriate action could facilitate rupture repair. We provide clinical examples of rupture and repair and discuss the opportunities that "the other side of the coin" presents for professional and personal growth. J Orthop Sports Phys Ther 2022;52(8):500-504. Epub: 19 June 2022. doi:10.2519/jospt.2022.11152.

Comparing what the clinician draws on a digital pain map to that of persons who have greater trochanteric pain syndrome

OBJECTIVES

To assess the agreements and differences in pain drawings (pain area, shape and location) between individuals who have greater trochanteric pain syndrome (GTPS) and their clinician.

METHODS

In this study, 23 patients with GTPS (21 female, pain duration range 8-24 months) underwent clinical evaluation by a registered physiotherapist. Digital 2d full body pain drawings were independently performed by the clinician during the subjective examination and by the patient following the physical examination. Levels of agreement [LoA] in the pain area were assessed with Bland-Altman plots. Differences in pain drawings were assessed visually by overlaying images, and by quantifying the differences in shape and location with the bounding box, and Jaccard index, respectively.

RESULTS

Pain areas (/total pixels of the charts) did not differ in size (LoA mean difference less than -0.5%; range -2.35-1.56%) or shape (bounding box p>0.17). However, there was minimal overlap in location (Jaccard index range 0.09-0.18/1 for perfect overlap).

CONCLUSIONS

Patients and the clinician displayed differences in location of pain areas, but not size or shape, when they independently performed digital pain drawings. The reasons that underlie and the clinical impact of these differences remains unclear.

Knee-extensor strength, symptoms, and need for surgery after two, four, or six exercise sessions/week using a home-based one-exercise program: a randomized dose-response trial of knee-extensor resistance exercise in patients eligible for knee replacement (the QUADX-1 trial)

OBJECTIVE

To investigate firstly the efficacy of three different dosages of one home-based, knee-extensor resistance exercise on knee-extensor strength in patients eligible for knee replacement, and secondly, the influence of exercise on symptoms, physical function and decision on surgery.

METHOD

One-hundred and forty patients eligible for knee replacement were randomized to three groups: 2, 4 or 6 home-based knee-extensor resistance exercise-sessions per week (group 2, 4 and 6 respectively) for 12 weeks.

PRIMARY OUTCOME

isometric knee-extensor strength.

SECONDARY OUTCOMES

Oxford Knee Score, Knee injury and Osteoarthritis Outcome Score, average knee pain last week (0-10 numeric rating scale), 6-min walk test, stair climbing test, exercise adherence and "need for surgery".

RESULTS

Primary analysis: Intention-to-treat analysis of 140 patients did not find statistically significant differences between the groups from baseline to after 12 weeks of exercise in isometric knee-extensor strength: Group 2 vs 4 (0.003 Nm/kg (0.2%) [95% CI -0.15 to 0.15], P = 0.965) and group 4 vs 6 (-0.04 Nm/kg (-2.7%) [95% CI -0.15 to 0.12], P = 0.628). Secondary analysis: Intention-to-treat analyses showed statistically significant differences between the two and six sessions/week groups in favor of the two sessions/week group for Oxford Knee Score: 4.8 OKS points (15.2%) [1.3 to 8.3], P = 0.008) and avg. knee pain last week (NRS 0-10): -1.3 NRS points (-19.5%) [-2.3 to -0.2], P = 0.018. After the 12-week exercise intervention, data were available for 117 patients (N = 39/group): 38 (32.5%) patients wanted surgery and 79 (67.5%) postponed surgery. This was independent of exercise dosage.

CONCLUSION

In patients eligible for knee-replacement we found no between-group differences in isometric knee extensor strength after 2, 4 and 6 knee-extensor resistance exercise sessions per week. We saw no indication of an exercise dose-response relationship for isometric knee-extensor strength and only clinically irrelevant within group changes. For some secondary outcome (e.g., KOOS subscales) we found clinically relevant within group changes, which could help explain why only one in three patients decided to have surgery after the simple home-based exercise intervention.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02931058. Preprint: https://doi.org/10.1101/2021.04.07.21254965.