Dysfunctional Endogenous Analgesia During Exercise in Patients with Chronic Pain: To Exercise or Not to Exercise?

The effect of exercise therapy on pain, fatigue, bone function and inflammatory biomarkers individuals with rheumatoid arthritis and knee osteoarthritis: a meta-research review of randomized controlled trials

Background

Accumulating evidence suggested the potential role of exercise in alleviating rheumatoid arthritis (RA). However, whether exercise improves physical function (walk test, grip strength, muscle strength, joint assessments) and inflammatory biomarkers in patients with RA is unclear. This umbrella meta-analysis aimed to examine the effect of exercise in patients with RA.

Method

PubMed, Scopus, Web of Science, Embase, and Cochrane Central Library databases were systematically searched for meta-analyses of randomized control trials (RCTs) to retrieve relevant studies. The effect sizes were pooled using a random-effects model, with standardized or weighted mean differences (SMDs or WMDs) and 95% confidence intervals (CIs) as summary statistics.

Results

Seventeen studies were included. The improving effects of exercise on fatigue levels (SMD = -0.28, 95% CI: -0.44, -0.13), pain intensity (ES = -0.50, 95% CI: -0.87, -0.14), disease activity score in joints (DAS) (WMD = -0.54, 95% CI: -0.99, -0.09; and SMD = -0.47, 95% CI: -0.64, -0.30), and ESR (ES = -0.85, 95% CI: -1.66, -0.03) were significant. No significant impact on the hand grip, muscle strength, walk test, joints and inflammatory biomarkers was observed.

Conclusion

Exercise significantly reduces fatigue, pain, DAS, and ESR in RA but shows no impact on grip strength, muscle strength, walk test, joints, or other inflammatory biomarkers. This highlights its role in symptom management rather than broad physiological changes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Understanding Exercise-Induced Hypoalgesia: An Umbrella Review of Scientific Evidence and Qualitative Content Analysis

Background and Objectives: Exercise-induced hypoalgesia (EIH) is a topic of interest in the scientific community. This umbrella review aimed to analyze EIH research and compare it with public dissemination on X. Materials and Methods: We selected relevant EIH reviews that included a healthy population or patients with pain and studied exercise interventions. A systematic literature search was carried out in PubMed, Web of Science, SciELO, PEDro, and Google Scholar, employing the Population, Intervention, Comparison, and Outcome strategy. Data were extracted and summarized, and methodological quality was assessed with the Quality Assessment Scale for Systematic Reviews, and risk of bias with the Risk of Bias in Systematic Reviews tool. The Physical Activity Guidelines Advisor Committee was employed for evidence synthesis. Simultaneously, advanced X website searches gathered EIH-related content for analysis. Information from posts on X was qualitatively analyzed and contrasted with evidence in the literature. Results: We included nine systematic reviews and 17 narrative reviews. Systematic reviews presented high methodological quality. However, half had low risk of bias, while the other half presented high risk of bias. The EIH in healthy participants was controversial for some exercise modalities, such as aerobic exercise, and the influence of psychological variables. Modalities, such as isotonic resistance exercise, showed favorable effects on hypoalgesia. However, in patients with musculoskeletal pain, different exercise modalities did not generate EIH. X analysis unveiled a considerable representation of science-related content, although with prevalent misinterpretations of scientific evidence. Conclusions: EIH has been extensively studied, yet the certainty of evidence remains limited. While some exercise modalities demonstrate hypoalgesic effects in asymptomatic individuals, these effects remain unverified in patients with musculoskeletal pain. Moreover, the analysis of social media content highlights frequent misinterpretations of scientific evidence, particularly conflating hypoalgesia with analgesia. This underscores the need for more precise, evidence-based communication on social media platforms.

Effects of Sacroiliac Joint Manipulation on Autonomic Nervous System and Lower Abdominal Pain in Women with Primary Dysmenorrhoea: A Randomized Controlled Trial

Background and Objectives: Autonomic nervous system (ANS) disorders are responsible for primary dysmenorrhea and are closely linked to the spine. This study aims to evaluate the effects of sacroiliac joint manipulation on the ANS and lower abdominal pain in women with primary dysmenorrhea and proposes an alternative treatment method. Materials and Methods: A total of 40 participants were randomly assigned; however, 35 participants remained in the final analysis after 5 dropped out; they were assigned to either the sacroiliac joint manipulation group (n = 18) or the superficial heat therapy group (n = 17). Assessments included heart rate variability (HRV), visual analogue scale (VAS) scores for lower abdominal pain, the pressure pain threshold (PPT) of the sacroiliac joint, and the Moos Menstrual Distress Questionnaire (MMDQ) at baseline and after 4 weeks. Only the VAS and MMDQ scores were reassessed after 8 weeks to evaluate the sustained effects of the treatment. Results: Changes in HRV showed improvements in ANS balance only in the sacroiliac joint manipulation group (p < 0.05). It was found to be more effective than superficial heat therapy (p < 0.05). A significant decrease in lower abdominal pain following the intervention was observed in both groups (p < 0.05), along with the sustained effects of the treatment (p < 0.05). The MMDQ scores decreased after sacroiliac joint manipulation (p < 0.05), with greater improvements compared to the superficial heat therapy (p < 0.05). Conclusions: Sacroiliac joint manipulation positively affects ANS balance and is effective in alleviating lower abdominal pain and menstruation-related symptoms, with sustained effects observed over time. Therefore, sacroiliac joint manipulation can be an effective alternative treatment for women with primary dysmenorrhea.

Non-linear association between air pollutants and secondary sensitive skin in acne patients

BACKGROUND

There is a growing number of patients suffering from sensitive skin secondary to acne, but its prevalence and influencing factors are not yet well-understood.

OBJECTIVE

The aim of this study is to investigate the nonlinear relationship between air pollutants and secondary sensitive skin in acne patients.

METHODS

A cross-sectional study comprising 4325 acne outpatients in China was carried out between September 2021 and December 2022, employing a simple random sampling approach. Air pollutants data was derived from the nearest air quality monitoring station corresponding to the subjects' residential locations. Furthermore, socio-economic characteristics, biological attributes, and lifestyle data of patients were acquired via questionnaire surveys. The data were subsequently analyzed utilizing the XGBoost machine learning model.

RESULTS

A nonlinear relationship has been observed between secondary sensitive skin in acne patients and various factors, including particulate matter (PM2.5), inhalable particulate matter (PM10), ozone (O3), sulfur dioxide (SO2), nitrogen dioxide (NO2), carbon monoxide (CO), the severity of depression, different levels of exercise intensity, acne grading, frequency of sunscreen application, gender, and age.

CONCLUSION

The occurrence of secondary sensitive skin in acne patients be mitigated through the implementation of measures such as the control of air pollutant emissions, regulation of negative emotions, and improvement of personal lifestyle.

Effects of lower-limb active resistance exercise on mobility, physical function, knee strength and pain intensity in patients with total knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Total knee arthroplasty (TKA) successfully alleviates pain from knee osteoarthritis, but muscle strength and function are reduced for a long period postoperatively. Postoperative active resistance exercise may play a relevant role.

PURPOSE

To systematically evaluate effects of lower-limb active resistance exercise (ARE) on mobility, physical function, muscle strength and pain intensity in patients with TKA.

METHODS

A search was conducted in PubMed, EMBASE, and Cochrane Library databases from inception to September 2023. Only randomized controlled trials (RCTs) that compared the effects of ARE and no intervention or other rehabilitation program without PRE were included. The outcome variables were mobility (Maximal walking speed [MWS]/6-Minute Walk Test[6MWT]), physical function (Stair Climb Test [SCT]/Timed Up and Go [TUG]), knee extension/ flexion power(KEP/KFP), joint range of motion (ROM) and pain. Standardized Mean Differences (SMD) or Mean Differences (MD) and 95% confidence intervals (CI) were calculated and combined in meta-analyses. The Cochrane Collaboration's Handbook were used for the methodological quality assessments. GRADE was used to assess the quality of evidence. The meta-analysis was performed using the RevMan 5.4 software.

RESULTS

A total of 14 randomized controlled trials, involving 880 patients, were finally included. The lower-limb ARE exhibited significantly greater improvement in MWS (MD 0.13, 95%CI 0.08-0.18, P < 0.00001), TUG(MD -0.92, 95%CI -1.55- -0.28, P = 0.005), KEP (SMD 0.58, 95%CI 0.20-0.96, P = 0.003), KFP (SMD 0.38, 95%CI 0.13-0.63, P = 0.003), ROM-flexion (MD 2.74, 95%CI 1.82-3.67, P < 0.00001) and VAS (MD - 4.65, 95% CI - 7.86- -1.44, p = 0.005) compared to conventional exercise(CE) immediately post-intervention. However, there were no statistically significant differences between both groups in regard to 6MWT (MD 7.98, 95%CI -4.60-20.56, P = 0.21), SCT (MD -0.79, 95%CI -1.69-0.10, P = 0.08) and ROM-extension (MD -0.60, 95%CI -1.23-0.03, P = 0.06).

CONCLUSIONS

According to the results of meta-analysis, patients undergoing TKA who receive the lower extremity ARE show better clinical effects in terms of pain relief, strength recovery and knee ROM. Simultaneously, it may be beneficial to improve mobility and physical function of patients after TKA.

Opioid and Cannabinoid Systems in Pain: Emerging Molecular Mechanisms and Use in Clinical Practice, Health, and Fitness

Pain is an unpleasant sensory and emotional experience. Adequate pain control is often challenging, particularly in patients with chronic pain. Despite advances in pain management, drug addiction, overtreatment, or substance use disorders are not rare. Hence the need for further studies in the field. The substantial progress made over the last decade has revealed genes, signalling pathways, molecules, and neuronal networks in pain control thus opening new clinical perspectives in pain management. In this respect, data on the epigenetic modulation of opioid and cannabinoid receptors, key actors in the modulation of pain, offered new perspectives to preserve the activity of opioid and endocannabinoid systems to increase the analgesic efficacy of opioid- and cannabinoid-based drugs. Similarly, upcoming data on cannabidiol (CBD), a non-psychoactive cannabinoid in the marijuana plant Cannabis sativa, suggests analgesic, anti-inflammatory, antioxidant, anticonvulsivant and ansiolitic effects and supports its potential application in clinical contexts such as cancer, neurodegeneration, and autoimmune diseases but also in health and fitness with potential use in athletes. Hence, in this review article, we summarize the emerging epigenetic modifications of opioid and cannabinoid receptors and focus on CBD as an emerging non-psychoactive cannabinoid in pain management in clinical practice, health, and fitness.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPACT

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

Exercise-Induced Hypoalgesia in Patients with Chronic Whiplash-Associated Disorders: Differences between Subgroups Based on the Central Sensitization Inventory

BACKGROUND

Physical exercise is an important element in the rehabilitation of chronic whiplash-associated disorders, with the physiological process underlying pain reduction called exercise-induced hypoalgesia. In chronic whiplash-associated disorders, exercise-induced hypoalgesia appears impaired, and the research suggests a relationship with symptoms of dysfunctional nociceptive processing, such as central sensitization. This study improves our understanding of exercise-induced hypoalgesia in chronic whiplash-associated disorders by examining the differences between the extent of exercise-induced hypoalgesia in subgroups based on scores on the central sensitization inventory (CSI).

METHODS

Data were collected from 135 participants with chronic whiplash-associated disorders who completed a set of questionnaires. Pain pressure thresholds and temporal summations were assessed before and after a submaximal aerobic bicycle exercise test.

RESULTS

We observed no interaction effect between exercise-induced hypoalgesia and the CSI scores for both pain pressure threshold and temporal summation. No overall statistical effect was measured in the analysis of the effect of time. The pain pressure threshold significantly related to the CSI. The temporal summation showed no correlation.

CONCLUSIONS

During this study, we did not find evidence for a difference in the presence of exercise-induced hypoalgesia when the subgroups were created based on the central sensitization cluster calculator. Limited evidence was found for the influence of CSI scores on the delta pain pressure threshold.

Exercise therapy for knee osteoarthritis pain: how does it work? A study protocol for a randomised controlled trial

INTRODUCTION

Muscle strengthening training (MST) and behavioural graded activity (BGA) show comparable effects on knee osteoarthritic (KOA) pain, but the mechanisms of action remain unclear. Both exercise-induced anti-inflammation and central sensitisation are promising pathways for pain relief in response to exercise therapy in patients with KOA: MST has the potential to decrease inflammation and BGA has the potential to decrease central sensitisation. Hence, this study aims to examine inflammation and central sensitisation as mediators for the effect of MST and/or BGA on pain in patients with KOA.

METHODS AND ANALYSIS

The Knee OsteoArthritis PAIN trial started on 10 January 2020 (anticipated end: April 2024). The three-arm clinical trial aims to recruit 90 KOA patients who will be randomly allocated to 12 weeks of (1) MST, (2) BGA or (3) care as usual. Assessments will be performed at baseline, 13 and 52 weeks after finishing the intervention. Outcomes, including pain (Knee injury and Osteoarthritis Outcome Score), were chosen in line with the OARSI recommendations for clinical trials of rehabilitation interventions for OA and the IMMPACT/OMERACT recommendations for the assessment of physical function in chronic pain clinical trials. Inflammation as well as features of central sensitisation (including conditioned pain modulation, offset analgesia, temporal summation of pain and event-related potentials following electrical stimulation), will be considered as treatment mediators. A multiple mediators model will be estimated with a path-analysis using structural equation models. In July 2023, all 90 KOA patients have been included and 42 participants already finished the study.

ETHICS AND DISSEMINATION

This study obtained ethics approval (B.U.N. 143201941843). Unravelling the mechanisms of action of exercise therapy in KOA will not only be extremely valuable for researchers, but also for exercise immunology and pain scientists and clinicians.

TRIAL REGISTRATION NUMBER

NCT04362618.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endogenous Opioids and Exercise-Related Hypoalgesia: Modern Models, Measurement, and Mechanisms of Action

This chapter will focus on the role exercise appears to have on activation and modulating factors within the central nervous system related to endogenous like opioids and its possible contribution to exercise-induced hypoalgesia. The implications for the exercise-mediated alterations of CNS activation factors related to opioids, specifically endorphins and enkephalins, will be presented. In this update, we discuss utilization of new technology and methods to monitor mechanisms of opioid involvement to suggest their contribution with exercise mediated hypoalgesia as well as their relationships to alterations of perceptions of pain and mood. Several special populations were included to suggest that not all individuals will respond to the exercise by mediating hypoalgesia. Factors that may confound the current understanding and suggestions from the recent literature will be presented as well as suggestions for future investigations.

A review of factors influencing sensitive skin: an emphasis on built environment characteristics

Background

Sensitive skin (SS) is a condition characterized by hyperreactivity. Impacting around 37 percent of the worldwide population and exerting an influence on the quality of life for affected individuals. Its prevalence rate has increased due to factors such as elevating stress levels and deteriorating environmental conditions. The exposome factors influencing SS have extended from demographic, biological attributes, and lifestyle to external environments. Built environments (BEs) have demonstrated as root drivers for changes in behaviors and environmental exposure which have the potential to trigger SS, but the review of the associations between BEs and SS is currently lacking.

Objective

This review aims to achieve two primary objectives: (1) Examine exposome factors that exert influence on SS at the individual and environmental levels. (2) Develop a theoretical framework that establishes a connection between BEs and SS, thereby offering valuable insights into the impact of the built environment on this condition.

Methods

An extensive literature search was carried out across multiple fields, including sociology, epidemiology, basic medicine, clinical medicine, and environmental research, with a focus on SS. To identify pertinent references, renowned databases such as PubMed, Web of Science, and CNKI were utilized.

Results

SS is the outcome of interactions between individual attributes and environmental factors. These influencing factors can be categorized into five distinct classes: (1) demographic and socioeconomic characteristics including age, gender, and race; (2) physiological and biological attributes such as emotional changes, skin types, sleep disorders, and menstrual cycles in women; (3) behavioral factors, such as spicy diet, cosmetic use, alcohol consumption, and physical exercise; (4) natural environmental features, including climate conditions and air pollution; (5) built environmental features such as population density, green space availability, road network density, and access to public transportation, also have the potential to affect the condition.

Conclusion

The importance of interdisciplinary integration lies in its ability to ascertain whether and how BEs are impacting SS. By elucidating the role of BEs in conjunction with other factors in the onset of SS, we can provide guidance for future research endeavors and the formulation of interventions aimed at mitigating the prevalence of SS.

COVID-19 and musculoskeletal pain: an overview of the current knowledge

The Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) has provoked billions of infections worldwide. Several meta-analyses have observed that up to 50% of individuals who had survived to a SARS-CoV-2 acute infection suffer from post-COVID symptoms lasting for weeks or months and up to one year after infection. The prevalence of post-COVID pain ranges between 10% to 20% when assessed with other overall post-COVID symptoms and can reach up to 50% to 60% when investigated specifically. The most common musculoskeletal manifestations of post-COVID-19 condition include fatigue, myalgia, arthralgia or back pain. Despite pain of musculoskeletal origin is one of the most prevalent post-COVID pain symptoms, the exact pathophysiological mechanisms of musculoskeletal post-COVID pain are not completely understood. Studies have reported the complexity of post-COVID pain including immune, biological, and psychological factors, and more recently, they have suggested that genetic and epigenetic factors may also play a potential role, highlighting the need for further investigation into these mechanisms. Its management is still controversial, as no specific guideline for treating musculoskeletal post-COVID pain has been proposed with only general consideration about the relevance of multidisciplinary and multimodal treatment approaches. In this paper we will highlight the clinical features, the mechanism, and the management possibilities of musculoskeletal post-COVID pain.

Effects of progressive intensity resistance training on the impact of fibromyalgia: protocol for a blinded randomized controlled trial

BACKGROUND

Fibromyalgia guidelines indicate that exercise is critical in the management of fibromyalgia, and there is evidence that patients with fibromyalgia can perform resistance training at moderate and high intensities. However, despite the biological plausibility that progression of intensity provides greater benefit to individuals, no studies have compared different intensities (progressive versus constant intensities) of the same exercise in this population.

OBJECTIVE

To compare the effect of 24 sessions of resistance training (progressive vs. constant intensity) on impact of fibromyalgia, sleep quality, anxiety, depression, pain, walking ability, and musculoskeletal capacity.

METHODS

A protocol for a blinded randomized controlled trial. The sample will be randomized into three groups: group 1 (progressive intensity, experimental), group 2 (constant intensity, control A), and group 3 (walking, control B). Group 1 will perform resistance training at moderate intensity (50% of maximum dynamic strength), previously determined by the 1 repetition maximum (1-RM) test in the proposed exercises. The strength of each individual will be reassessed every 4 weeks (by 1-RM) and the intensity of each exercise will be positively adjusted by 20% of the value observed in kg (i.e., first month 50%; second month 70%; third month 90% of the maximum dynamic strength). Group 2 will perform the same procedure, but the intensity will be maintained at 50% of the maximum dynamic strength throughout the treatment (i.e., constant intensity from the first to the third month). Group 3 will perform a 40-minute treadmill walk at low intensity, defined by a walking speed corresponding to 60-70% of the maximum heart rate, which we will control with a heart rate monitor. All groups will receive a 45-minute pain education session prior to the exercise program, covering the pathophysiologic mechanisms of chronic pain, strategies for coping with pain, avoiding hypervigilance, and deconstructing beliefs and myths about chronic pain.

DISCUSSION

The results of the present study may help health care professionals adjust the intensity of resistance training and thus plan the most effective intervention (progressive or constant intensity) to reduce the impact of fibromyalgia on patients' lives.

TRIAL REGISTRATION

Brazilian Registry of Clinical Trials (ReBEC) ID: RBR-9pbq9fg, date of registration: October 06, 2022.

Are clinical outcomes associated with baseline sensory profiles in people with musculoskeletal shoulder pain? Protocol for a prospective longitudinal observational study

BACKGROUND

Musculoskeletal shoulder pain is a common problem and its symptoms often become persistent. The experience of pain is multidimensional, and therefore, a range of patient characteristics may influence treatment response. An altered sensory processing has been associated with persistent musculoskeletal pain states and may contribute to outcomes in patients with musculoskeletal shoulder pain. The presence and potential impact of altered sensory processing in this patient cohort is not currently known. The aim of this prospective longitudinal cohort study is to investigate if baseline sensory characteristics are associated with clinical outcomes in patients presenting to a tertiary hospital with persistent musculoskeletal shoulder pain. If found, a relationship between sensory characteristics and outcome may lead to the creation of more effective treatment strategies and improvements in risk adjustment and prognosis.

METHODS

This is a single-centre prospective cohort study with 6-, 12- and 24-month follow-up. A total of 120 participants aged ≥18 years with persistent musculoskeletal shoulder pain (≥3 months) will be recruited from an Australian public tertiary hospital orthopaedic department. Baseline assessments, including quantitative sensory tests and a standardised physical examination, will be performed. In addition, information will be obtained from patient interviews, self-report questionnaires and medical records. Follow-up outcome measures will comprise information from the Shoulder Pain and Disability Index and a six-point Global Rating of Change scale.

ANALYSIS

Descriptive statistics will be used to report baseline characteristics and outcome measures over time. Change in outcome measures at the primary endpoint of six months from baseline will be calculated using paired t-tests. Associations between baseline characteristics and outcomes at a 6-month follow-up will be reported using multivariable linear and logistic regression models.

DISCUSSION

Understanding the relationship between sensory profile and the variable response to treatment in people with persistent musculoskeletal shoulder pain may enhance our understanding of the mechanisms contributing to the presentation. In addition, through better understanding of the contributing factors, the results of this study may contribute to the development of an individualised, patient-centred approach to treatment for people with this highly prevalent and debilitating condition.

Virtual Reality-Based Exercise Therapy for Patients with Chronic Musculoskeletal Pain: A Scoping Review

This scoping review aimed to identify interventions utilizing virtual-reality-based exercise therapy in patients with chronic musculoskeletal pain. Searches were conducted in four databases using descriptors related to virtual reality, exercise, and chronic musculoskeletal pain. Two reviewers screened the titles and abstracts of the studies to assess eligibility, with a third author resolving any discrepancies. Data were extracted and summarized in a narrative format by three independent raters. Clinical trials were evaluated using the PEDro scale to assess the effectiveness of virtual-reality-based exercise therapy in chronic musculoskeletal pain patients. A total of 162 articles were identified from the databases. After applying the inclusion criteria, nine articles were considered suitable for analysis, including six randomized clinical trials. The selected articles were categorized based on study characteristics, virtual-reality-based exercise therapy interventions (including technologies and equipment used), exercise interventions, outcome measures, and effectiveness. The findings indicate that virtual-reality-based exercise therapy shows promising results in reducing pain, improving disability, enhancing range of motion, and increasing treatment satisfaction in patients with chronic musculoskeletal pain. However, it is not possible to conclude that virtual-reality-based exercise therapy is superior to other treatments due to the limited number of available studies, heterogeneity in application protocols, and varying methodological quality. Further research is needed to draw more definitive conclusions.

Physical Activity in Women with Endometriosis: Less or More Compared with a Healthy Control?

BACKGROUND

Endometriosis, i.e., endometrial-like tissue outside the uterus, is a chronic inflammatory condition affecting physical functioning. However, the specific levels of physical activity (PA) in the context of endometriosis and different disease symptoms remain unclear.

METHODS

This multi-center, cross-sectional study compared PA levels and influencing factors in endometriosis patients and non-endometriosis patients. Data were collected through questionnaires. Endometriosis was surgically confirmed. A statistical analysis was performed with appropriate tests.

RESULTS

The study included 460 women with endometriosis and 460 age-matched women without this condition. The two groups did not differ significantly in terms of age, education level, or stable partnership. Women with endometriosis exhibited lower PA levels, practicing fewer hours of sports weekly and climbing fewer stairs daily compared to the control group. These differences remained significant after controlling for confounding factors. Factors such as endometriosis, current dysmenorrhea, and depression were associated with decreased PA.

CONCLUSIONS

These findings suggest that women with endometriosis engage in less PA compared to those without this condition. These results highlight the need for interventions to promote increased PA in endometriosis patients and harness the associated health benefits. Further research is warranted to explore the underlying mechanisms and develop tailored exercise therapies for this population.

The Role of Serotonergic and Noradrenergic Descending Pathways on Performance-Based Cognitive Functioning at Rest and in Response to Exercise in People with Chronic Whiplash-Associated Disorders: A Randomized Controlled Crossover Study

(1) Background: Dysregulation in serotonergic and noradrenergic systems may be implicated in the neurobiophysiological mechanisms underlying pain-related cognitive impairment in chronic whiplash-associated disorders (CWAD). This study aimed to unravel the role of serotonergic and noradrenergic descending pathways in cognitive functioning at rest and in response to exercise in people with CWAD. (2) Methods: 25 people with CWAD were included in this double-blind, randomized, controlled crossover study. Endogenous descending serotonergic and noradrenergic inhibitory mechanisms were modulated by using a single dose of a selective serotonin reuptake inhibitor (Citalopram) or a selective norepinephrine reuptake inhibitor (Atomoxetine). Cognitive performance was studied at rest and in response to exercise (1) without medication intake; (2) after intake of Citalopram; and (3) after intake of Atomoxetine. (3) Results: After Atomoxetine intake, selective attention improved compared with the no medication day (p < 0.05). In contrast, a single dose of Citalopram had no significant effect on cognitive functioning at rest. When performing pairwise comparisons, improvements in selective attention were found after exercise for the no medication condition (p < 0.05). In contrast, after intake of Citalopram or Atomoxetine, selective and sustained attention worsened after exercise. (4) Conclusions: A single dose of Atomoxetine improved selective attention only in one Stroop condition, and a single dose of Citalopram had no effect on cognitive functioning at rest in people with CWAD. Only without medication intake did selective attention improve in response to exercise, whereas both centrally acting medications worsened cognitive performance in response to a submaximal aerobic exercise bout in people with CWAD.

Factors Predicting Nonadherence to Treatment Recommendations for Patients With Chronic Low Back Pain in India: A Cross-Sectional Survey

OBJECTIVE

The purpose of this study was to examine patients' expectations and factors that influence adherence to physiotherapists' treatment recommendations on chronic low back pain (CLBP).

METHOD

One hundred and forty seven patients with CLBP were included in this study. Predictive indicators including demographic information, views, expectations, and opinions regarding the health status and treatment expectations of patients were derived from questionnaires. The dependent outcome variables were the absence of trust in treatment recommendations provided by physiotherapists, the anticipation of treatment recommendations based on patient expectations, and the resistance to modifying expectations despite efforts by physiotherapists to persuade otherwise. The study was carried out between April 2022 and January 2023 in 2 regions located in India.

RESULTS

Multivariate regression analyses show that age, expectations about diagnosis, preference for passive therapies and medical care, and information seeking behavior emerged as independent predictors of a lack of trust in physiotherapists' treatment recommendations. The information-seeking behavior of the patients' alone predicted the anticipation of treatment recommendations based on patient expectations and the reluctance to alter those expectations despite the physiotherapists' persuasion.

CONCLUSION

Our results suggest that information seeking behavior is the most consistent independent predictor of treatment expectations that will align with physiotherapist recommendations. This indicates the importance of screening for such factors and the importance of patient education to optimize the management of CLBP. However, larger studies incorporating all variables associated with patient expectations in similar patient populations are needed to confirm these results.

Effectiveness of motor control exercise, aerobic walking, and muscle strengthening programs in improving outcomes in a subgroup of population with chronic low back pain positive for central sensitization: a study protocol for a randomized controlled trial

BACKGROUND

The role of pain sensitivity in the development and maintenance of chronic pain states, impaired executive functioning, and patient recovery is being investigated. Conditioned pain modulation (CPM) is widely used to measure musculoskeletal pain associated with central sensitization (CS). Despite the recommendations of many reviews and clinical practice guidelines that exercise programs reduce pain and disability, the overall confidence in these results is considered "critically low." The "active ingredient" of exercise programs and the dominant factor influencing CPM remain largely unknown. The objectives of this trial are to determine: • If different exercises cause different results on the CPM in a subgroup of people with chronic low back pain (CLBP) who are labeled as having CS pain, • If a program of exercise interventions for 12 weeks would alter executive functioning, quality of life (QoL), disability, and pain in persons with CLBP. • The relationship between patient characteristics, executive functions, CPM, and QoL METHODS: The trial is a randomized, controlled, multi-center study with four experimental groups and one healthy control group. Both the researchers and the people in the study will be blinded to the results. This paper describes the protocol for a trial examining the effects of 12-week individualized, twice-weekly exercise sessions lasting 30 to 60 min in persons with CLBP, who are positive for CS. Participants will be randomized to receive either patient education with motor control exercises (MCE), superficial strengthening (SS), aerobic exercises (AE), or patient education alone. Another group comprised of healthy volunteers will serve as controls. The primary outcomes are changes in CPM outcomes as measured by the cold pressor test (CPT). The secondary objectives are to evaluate executive functioning, pain, disability, quality of life, and spine muscle strength. The outcomes will be measured at 3 months and at a 6-month follow-up.

DISCUSSION

The outcomes of the study will help in gaining more information and evidence about exercise-induced analgesia from the perspective of CPM. Measuring exercise outcomes will aid in scientifically prescribing exercise prescriptions in people with CLBP. The study outcomes will also assist in identifying the characteristics of individuals who will respond or respond indifferently to exercises. Investigating the relationship between the study's various outcomes could provide information for future trials.

TRIAL REGISTRATION

Clinical Trials Registry of India (CTRI) identifier: CTRI/2022/03/041143. Registered on 16 March 2022.

[Physiotherapeutic therapy modalities for lateral epicondyopathy]

Physiotherapy interventions can have a positive effect on the symptoms and relief of symptoms of lateral epicondylopathy (LE). However, there is currently no standard physiotherapy protocol for treating LE. Today, a multimodal treatment approach that focuses on progressive exercise therapy is recommended. While in the past, most treatment protocols were based on eccentric training, recent research shows that other forms of training can also improve pain and function in tendinopathies.

Task-based measures of sensitivity to physical activity predict daily life pain and mood among people living with back pain

BACKGROUND

Clinical interventions aim to improve the daily life experiences of patients. However, past research has highlighted important discrepancies between commonly used assessments (e.g. retrospective questionnaires) and patients' daily life experiences of pain. These gaps may contribute to flawed clinical decision-making and ineffective care. Recent work suggests that real-time, task-based clinical assessments may help reduce these discrepancies by adding predictive value in explaining daily life pain experiences. This study aimed to investigate these relationships by evaluating whether task-based measures of sensitivity to physical activity (SPA) predict daily life pain and mood, beyond traditional pain-related questionnaires.

METHODS

Adults with back pain (<6-month onset) answered pain-related questionnaires and completed a standardized lifting task. SPA-Pain, SPA-Sensory and SPA-Mood were, respectively, assessed as task-evoked changes in pain intensity, pressure pain threshold (back, hands), situational catastrophizing. Over the next 9 days, daily life pain and mood were assessed using smartphone-based ecological momentary assessment (EMA-Pain and EMA-Mood, respectively) with stratified random sampling. Data analyses estimated fixed effects (b) using multilevel linear modelling with random intercepts.

RESULTS

Median EMA completion per participant was 66.67% (n = 67 participants). After controlling for covariates, SPA-Pain was associated with EMA-Pain (b = 0.235, p = 0.002) and SPA-Psych approached significance with EMA-Mood (b = -0.159, p = 0.052).

CONCLUSIONS

Task-based assessment of SPA helps explain daily life pain and mood among adults with back pain, beyond traditional questionnaires. Adding task-based assessment of SPA may achieve a more complete picture of pain and mood in daily life, offering clinicians better guidance when prescribing activity-based interventions that are designed to modify daily life behaviour, such as graded activity.

SIGNIFICANCE

This study found that, among people with back pain, task-based measures of sensitivity to physical activity contribute additional predictive value for daily life pain and mood beyond self-report questionnaires. Findings suggest that real-time, task-based measures may help mitigate some of the shortcomings that are commonly associated with retrospective questionnaires.

Effectiveness of therapeutic exercise and cognitive-behavioural therapy combined protocol on functionality, pain and joint health in people with haemophilia: Secondary analysis of a controlled trial

BACKGROUND

Haemophilic arthropathy is one of the main causes of morbidity in people with haemophilia (PWH), inducing pain and reduced functionality. Therefore, PWH are complex patients and must be approached from a multidisciplinary perspective.

OBJECTIVES

To evaluate the effectiveness of a therapeutic exercise and cognitive-behavioural therapy (CBT) combined protocol on functionality, pain, and joint health of PWH, arthropathy and chronic pain. Treatment satisfaction was also evaluated.

METHODS

A single-blinded clinical trial with 21 PWH in prophylactic regimen was carried out. Participants were divided into an experimental group (EG, n = 11) and a control group (CG, n = 10). The EG underwent a 4-month programme of home-based therapeutic exercise plus CBT, whilst CG performed their daily activities. Patients were evaluated at baseline, post-intervention and after 12 additional weeks. Measures of functionality (Haemophilia Activities List, Timed Up and Go Test, 2-Minutes-Walking-Test and Sit-to-Stand Test), pain (PainDETECT and Visual Analogue Scale) and joint health (Haemophilia Joint Health Score) were taken. Related dimensions of the A36 Haemophilia Quality of Life Questionnaire were calculated. Effects were calculated using a two-factor ANOVA.

RESULTS

The EG showed significant improvements in function (p < .001), pain (p < .001), joint damage (p = .006), and satisfaction with the treatment (p = .006) dimensions of the A36 Haemophilia Quality of Life Questionnaire, as well as in pain measured with the Visual Analogue Scale (p = .008) and PainDETECT (p = .035).

CONCLUSIONS

The combined physiotherapy and CBT protocol showed a partial improvement in functionality, pain and joint health of PWH, arthropathy and chronic pain. In addition, participants were satisfied with the treatment.

The autonomic and nociceptive response to acute exercise is impaired in people with knee osteoarthritis

Objectives

An acute bout of exercise typically leads to short term exercise induced hypoalgesia (EIH), but this response is more variable in many chronic pain populations, including knee osteoarthritis (OA) and fibromyalgia (FM). There is evidence of autonomic nervous system (ANS) dysfunction in some chronic pain populations that may contribute to impaired EIH, but this has not been investigated in people with knee OA. The aim of this study was to assess the acute effects of isometric exercise on the nociceptive and autonomic nervous systems in people with knee OA and FM, compared to pain-free controls.

Methods

A cross-sectional study was undertaken with 14 people with knee OA, 13 people with FM, and 15 pain free controls. Across two experimental sessions, baseline recordings and the response of the nociceptive and autonomic nervous systems to a 5-min submaximal isometric contraction of the quadriceps muscle was assessed. The nociceptive system was assessed using pressure pain thresholds at the knee and forearm. The ANS was assessed using high frequency heart rate variability, cardiac pre-ejection period, and electrodermal activity. Outcome measures were obtained before and during (ANS) or immediately after (nociceptive) the acute bout of exercise.

Results

Submaximal isometric exercise led to EIH in the control group. EIH was absent in both chronic pain groups. Both chronic pain groups showed lower vagal activity at rest. Furthermore, people with knee OA demonstrated reduced vagal withdrawal in response to acute isometric exercise compared to controls. Sympathetic reactivity was similar across groups.

Discussion

The findings of reduced tonic vagal activity and reduced autonomic modulation in response to isometric exercise raise the potential of a blunted ability to adapt to acute exercise stress and modulate nociception in people with knee OA. The impairment of EIH in knee OA may, in part, be due to ANS dysfunction.

International, multidisciplinary Delphi consensus recommendations on non-pharmacological interventions for fibromyalgia

OBJECTIVES

To develop evidence-based expert recommendations for non-pharmacological treatments for pain, fatigue, sleep problems, and depression in fibromyalgia.

METHODS

An international, multidisciplinary Delphi exercise was conducted. Authors of EULAR and the Canadian Fibromyalgia Guidelines Group, members of the American Pain Society and clinicians with expertise in fibromyalgia were invited. Participants were asked to select non-pharmacological interventions that could be offered for specific fibromyalgia symptoms and to classify them as either core or adjunctive treatments. An evidence summary was provided to aid the decision making. Items receiving >70% votes were accepted, those receiving <30% votes were rejected and those obtaining 30-70% votes were recirculated for up to two additional rounds.

RESULTS

Seventeen experts participated (Europe (n = 10), North America (n = 6), and Israel (n = 1)) in the Delphi exercise and completed all three rounds. Aerobic exercise, education, sleep hygiene and cognitive behavioural therapy were recommended as core treatments for all symptoms. Mind-body exercises were recommended as core interventions for pain, fatigue and sleep problems. Mindfulness was voted core treatment for depression, and adjunctive treatment for other symptoms. Other interventions, namely music, relaxation, hot bath, and local heat were voted as adjunctive treatments, varying between symptoms.

CONCLUSIONS

This study provided evidence-based expert consensus recommendations on non-pharmacological treatments for fibromyalgia that may be used to individualise treatments in clinical practice targeting the diverse symptoms associated with fibromyalgia.

It Hurts to Move! Intervention Effects and Assessment Methods for Movement-Evoked Pain in Patients With Musculoskeletal Pain: A Systematic Review with Meta-analysis

OBJECTIVES

To estimate the effects of musculoskeletal rehabilitation interventions on movementevoked pain and to explore the assessment methods/protocols used to evaluate movement-evoked pain in adults with musculoskeletal pain.

DESIGN

Systematic review with meta-analysis.

LITERATURE SEARCH

Three electronic databases (PubMed, Web of Science, and Scopus) were searched.

STUDY SELECTION CRITERIA

Randomized controlled trials investigating musculoskeletal rehabilitation interventions for movement-evoked pain in adults with musculoskeletal pain were included.

DATA SYNTHESIS

Meta-analysis was conducted for outcomes with homogeneous data from at least 2 trials. The mean change in movementevoked pain was the primary outcome measure. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation framework.

RESULTS

Thirty-eight trials were included, and 60 different interventions were assessed. There was moderate-certainty evidence of a beneficial effect of exercise therapy compared to no treatment (standardized mean difference [SMD], -0.65; 95% confidence interval [CI]: -0.83, -0.47; P<.001) on movement-evoked pain in adults with musculoskeletal pain. There was low-certainty evidence of a beneficial effect of transcutaneous electrical nerve stimulation compared to no treatment (SMD, -0.46; 95% CI: -0.71, -0.21; P = .0004). There was no benefit of transcutaneous electrical nerve stimulation when compared to sham transcutaneous electrical nerve stimulation (SMD, -0.28; 95% CI: -0.60, 0.05; P = .09; moderate-certainty evidence).

CONCLUSION

There was moderate-certainty evidence that exercise therapy is effective for reducing movement-evoked pain in patients with musculoskeletal pain compared to no treatment. Consider exercise therapy as the first-choice treatment for movement-evoked pain in clinical practice. J Orthop Sports Phys Ther 2022;52(6):345-374. Epub: 05 Feb 2022. doi:10.2519/jospt.2022.10527.

Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II

BACKGROUND

Complex regional pain syndrome (CRPS) is a painful and disabling condition that usually manifests in response to trauma or surgery and is associated with significant pain and disability. CRPS can be classified into two types: type I (CRPS I) in which a specific nerve lesion has not been identified and type II (CRPS II) where there is an identifiable nerve lesion. Guidelines recommend the inclusion of a variety of physiotherapy interventions as part of the multimodal treatment of people with CRPS. This is the first update of the review originally published in Issue 2, 2016.

OBJECTIVES

To determine the effectiveness of physiotherapy interventions for treating pain and disability associated with CRPS types I and II in adults.

SEARCH METHODS

For this update we searched CENTRAL (the Cochrane Library), MEDLINE, Embase, CINAHL, PsycINFO, LILACS, PEDro, Web of Science, DARE and Health Technology Assessments from February 2015 to July 2021 without language restrictions, we searched the reference lists of included studies and we contacted an expert in the field. We also searched additional online sources for unpublished trials and trials in progress.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of physiotherapy interventions compared with placebo, no treatment, another intervention or usual care, or other physiotherapy interventions in adults with CRPS I and II. Primary outcomes were pain intensity and disability. Secondary outcomes were composite scores for CRPS symptoms, health-related quality of life (HRQoL), patient global impression of change (PGIC) scales and adverse effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened database searches for eligibility, extracted data, evaluated risk of bias and assessed the certainty of evidence using the GRADE system.

MAIN RESULTS

We included 16 new trials (600 participants) along with the 18 trials from the original review totalling 34 RCTs (1339 participants). Thirty-three trials included participants with CRPS I and one trial included participants with CRPS II. Included trials compared a diverse range of interventions including physical rehabilitation, electrotherapy modalities, cortically directed rehabilitation, electroacupuncture and exposure-based approaches. Most interventions were tested in small, single trials. Most were at high risk of bias overall (27 trials) and the remainder were at 'unclear' risk of bias (seven trials). For all comparisons and outcomes where we found evidence, we graded the certainty of the evidence as very low, downgraded due to serious study limitations, imprecision and inconsistency. Included trials rarely reported adverse effects. Physiotherapy compared with minimal care for adults with CRPS I One trial (135 participants) of multimodal physiotherapy, for which pain data were unavailable, found no between-group differences in pain intensity at 12-month follow-up. Multimodal physiotherapy demonstrated a small between-group improvement in disability at 12 months follow-up compared to an attention control (Impairment Level Sum score, 5 to 50 scale; mean difference (MD) -3.7, 95% confidence interval (CI) -7.13 to -0.27) (very low-certainty evidence). Equivalent data for pain were not available. Details regarding adverse events were not reported. Physiotherapy compared with minimal care for adults with CRPS II We did not find any trials of physiotherapy compared with minimal care for adults with CRPS II.

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effects of physiotherapy interventions on pain and disability in CRPS. This conclusion is similar to our 2016 review. Large-scale, high-quality RCTs with longer-term follow-up are required to test the effectiveness of physiotherapy-based interventions for treating pain and disability in adults with CRPS I and II.

Aerobic Physical Exercise as a Non-medical Intervention for Brain Dysfunction: State of the Art and Beyond

Brain disorders, including stroke, Alzheimer's disease, depression, and chronic pain, are difficult to effectively treat. These major brain disorders have high incidence and mortality rates in the general population, and seriously affect not only the patient's quality of life, but also increases the burden of social medical care. Aerobic physical exercise is considered an effective adjuvant therapy for preventing and treating major brain disorders. Although the underlying regulatory mechanisms are still unknown, systemic processes may be involved. Here, this review aimed to reveal that aerobic physical exercise improved depression and several brain functions, including cognitive functions, and provided chronic pain relief. We concluded that aerobic physical exercise helps to maintain the regulatory mechanisms of brain homeostasis through anti-inflammatory mechanisms and enhanced synaptic plasticity and inhibition of hippocampal atrophy and neuronal apoptosis. In addition, we also discussed the cross-system mechanisms of aerobic exercise in regulating imbalances in brain function, such as the “bone-brain axis.” Furthermore, our findings provide a scientific basis for the clinical application of aerobic physical exercise in the fight against brain disorders.

[Physiotherapy and health education protocol in chronic musculoskeletal shoulder pain. Experience in Primary Care]

Objetivo

Evaluar la experiencia de un programa de educación para la salud en atención primaria en pacientes con dolor de hombro crónico de origen musculoesquelético, sobre el dolor y la discapacidad e instaurar el protocolo en atención primaria.

Diseño

Estudio observacional descriptivo longitudinal quasi-experimental.

Emplazamiento

Centro de Salud Arroyo de la Vega. Alcobendas, Madrid.

Participantes

Pacientes remitidos por su médico de atención primaria a la unidad de fisioterapia de atención primaria por dolor de hombro de origen musculoesquelético.

Intervención

Siete sesiones grupales de educación para la salud y ejercicio terapéutico.

Mediciones principales

Se valoró la intensidad del dolor a través de la escala visual analógica, la discapacidad del miembro superior con el cuestionario Disabilities of the Arm, Shoulder and Hand y el nivel de discapacidad y dolor de hombro con el questionario Shoulder Pain and Disability Index.

Resultados

Se encontraron diferencias estadísticamente significativas en la reducción del dolor y la discapacidad (p < 0,01), además se redujo el consumo de fármacos y las recidivas.

Conclusiones

El protocolo de fisioterapia de hombro con educación para la salud fue eficaz para reducir el dolor y la discapacidad en pacientes con dolor de hombro crónico, de origen musculoesquelético, en atención primaria.

Advances in targeting central sensitization and brain plasticity in chronic pain

Maladaptation in sensory neural plasticity of nociceptive pathways is associated with various types of chronic pain through central sensitization and remodeling of brain connectivity. Within this context, extensive research has been conducted to evaluate the mechanisms and efficacy of certain non-pharmacological pain treatment modalities. These include neurostimulation, virtual reality, cognitive therapy and rehabilitation. Here, we summarize the involved mechanisms and review novel findings in relation to nociceptive desensitization and modulation of plasticity for the management of intractable chronic pain and prevention of acute-to-chronic pain transition.

An Educational and Exercise Mobile Phone–Based Intervention to Elicit Electrophysiological Changes and to Improve Psychological Functioning in Adults With Nonspecific Chronic Low Back Pain (BackFit App): Nonrandomized Clinical Trial

Background

Concomitant psychological and cognitive impairments modulate nociceptive processing and contribute to chronic low back pain (CLBP) maintenance, poorly correlated with radiological findings. Clinical practice guidelines recommend self-management and multidisciplinary educational and exercise-based interventions. However, these recommendations are based on self-reported measurements, which lack evidence of related electrophysiological changes. Furthermore, current mobile health (mHealth) tools for self-management are of low quality and scarce evidence. Thus, it is necessary to increase knowledge on mHealth and electrophysiological changes elicited by current evidence-based interventions.

Objective

The aim of this study is to investigate changes elicited by a self-managed educational and exercise-based 4-week mHealth intervention (BackFit app) in electroencephalographic and electrocardiographic activity, pressure pain thresholds (PPTs), pain, disability, and psychological and cognitive functioning in CLBP versus the same intervention in a face-to-face modality.

Methods

A 2-arm parallel nonrandomized clinical trial was conducted at the University of the Balearic Islands (Palma, Spain). A total of 50 patients with nonspecific CLBP were assigned to a self-managed group (23/50, 46%; mean age 45.00, SD 9.13 years; 10/23, 43% men) or a face-to-face group (27/50, 54%; mean age 48.63, SD 7.54 years; 7/27, 26% men). The primary outcomes were electroencephalographic activity (at rest and during a modified version of the Eriksen flanker task) and heart rate variability (at rest), PPTs, and pressure pain intensity ratings. The secondary outcomes were pain, disability, psychological functioning (mood, anxiety, kinesiophobia, pain catastrophizing, and fear-avoidance beliefs), and cognitive performance (percentage of hits and reaction times).

Results

After the intervention, frequency analysis of electroencephalographic resting-state data showed increased beta-2 (16-23 Hz; 0.0020 vs 0.0024; P=.02) and beta-3 (23-30 Hz; 0.0013 vs 0.0018; P=.03) activity. In addition, source analyses revealed higher power density of beta (16-30 Hz) at the anterior cingulate cortex and alpha (8-12 Hz) at the postcentral gyrus and lower power density of delta (2-4 Hz) at the cuneus and precuneus. Both groups also improved depression (7.74 vs 5.15; P=.01), kinesiophobia (22.91 vs 20.87; P=.002), activity avoidance (14.49 vs 12.86; P<.001), helplessness (6.38 vs 4.74; P=.02), fear-avoidance beliefs (35 vs 29.11; P=.03), and avoidance of physical activity (12.07 vs 9.28; P=.01) scores, but there was an increase in the disability score (6.08 vs 7.5; P=.01). No significant differences between the groups or sessions were found in heart rate variability resting-state data, electroencephalographic data from the Eriksen flanker task, PPTs, subjective ratings, or cognitive performance.

Conclusions

Both intervention modalities increased mainly beta activity at rest and improved psychological functioning. Given the limitations of our study, conclusions must be drawn carefully and further research will be needed. Nevertheless, to the best of our knowledge, this is the first study reporting electroencephalographic changes in patients with CLBP after an mHealth intervention.

Trial Registration

ClinicalTrials.gov NCT04576611; https://clinicaltrials.gov/ct2/show/NCT04576611

The Benefits of a Therapeutic Exercise and Educational Intervention Program on Central Sensitization Symptoms and Pain-Related Fear Avoidance in Breast Cancer Survivors

BACKGROUND

Central sensitization symptoms and pain-related fear avoidance are two common problems in breast cancer survivors. Non-pharmacologic interventions such as therapeutic exercise and patient education can be effective in this population.

AIMS

This study aimed to: (1) analyze the benefits of a therapeutic exercise and educational program on central sensitization symptoms and pain-related fear avoidance in breast cancer survivors, and (2) explore the association between pain-related fear avoidance and central sensitization symptoms.

DESIGN

A single group pre-post intervention study was conducted.

METHODS

Patients were recruited from the service of Medical Oncology of the University Clinical Hospital Virgen de la Victoria, in Málaga (Spain). The intervention consisted of a therapeutic exercise and educational program that lasted 12 weeks, twice a week, for 1 hour. Two instruments were used: the Spanish version of the Central Sensitization Inventory and the Spanish Fear Avoidance Components Scale.

RESULTS

A total of 82 breast cancer survivors participated in the study. Pre-post change on Central Sensitization Inventory was statistically significant (p = .007). There was a trend towards a significant difference for the Spanish Fear Avoidance Components Scale (p = .062). There was a statistically significant correlation between pain-related fear avoidance and central sensitization symptoms (r = 0.536, p < .001).

CONCLUSIONS

The current study has provided preliminary evidence on the benefits of this intervention in pain-related fear avoidance and central sensitization symptoms in breast cancer survivors. The Spanish version of the Central Sensitization Inventory and the Spanish Fear Avoidance Components Scale demonstrated responsiveness to change.

Distinct aberrations in cerebral pain processing differentiating patients with fibromyalgia from patients with rheumatoid arthritis

ABSTRACT

The current study used functional magnetic resonance imaging to directly compare disease-relevant cerebral pain processing in well-characterized patient cohorts of fibromyalgia (FM, nociplastic pain) and rheumatoid arthritis (RA, nociceptive pain). Secondary aims were to identify pain-related cerebral alterations related to the severity of clinical symptoms such as pain intensity, depression, and anxiety. Twenty-six patients with FM (without RA-comorbidity) and 31 patients with RA (without FM-comorbidity) underwent functional magnetic resonance imaging while stimulated with subjectively calibrated painful pressures corresponding to a pain sensation of 50 mm on a 100-mm visual analogue scale. Stimulation sites were at the most inflamed proximal interphalangeal joint in the left hand in patients with RA and the left thumbnail in patients with FM, 2 sites that have previously been shown to yield the same brain activation in healthy controls. The current results revealed disease-distinct differences during pain modulation in RA and FM. Specifically, in response to painful stimulation, patients with FM compared to patients with RA exhibited increased brain activation in bilateral inferior parietal lobe (IPL), left inferior frontal gyrus (IFG)/ventrolateral prefrontal cortex (vlPFC) encapsulating left dorsolateral prefrontal cortex, and right IFG/vlPFC. However, patients with RA compared to patients with FM exhibited increased functional connectivity (during painful stimulation) between right and left IPL and sensorimotor network and between left IPL and frontoparietal network. Within the FM group only, anxiety scores positively correlated with pain-related brain activation in left dorsolateral prefrontal cortex and right IFG/vlPFC, which further highlights the complex interaction between affective (ie, anxiety scores) and sensory (ie, cerebral pain processing) dimensions in this patient group.

Development and Trial of a Prototype Device for Sensorimotor Therapy in Patients with Distal Radius Fractures

This study examined the clinical feasibility of a prototype device (development name: Ghost) for facilitating range of motion (RoM) recovery in the acute phase in patients with distal radius fractures (DRF). The Ghost device involves the administration of a combination of vibratory and visual stimuli. We divided the patients into the Ghost (n = 10) and control group (n = 4; tendon vibration only) groups. The experimental interventions were administered between the day after surgery and day 7 postoperatively. Traditional hand therapy was provided to both groups once daily from day 7 until day 84 postoperatively and once a week from day 84 until the end of the intervention period. Because vibratory stimulation makes the patient focus on wrist flexion, the primary outcome was the arc of wrist flexion-extension on the injured side, which was measured on days 7, 14, 28, 42, 56, 70, and 84. Analysis of covariance was applied using a bootstrap method to evaluate changes over time and compare them between the groups. Analyses was performed after stratification by age and body mass index. Both interventions improved RoM over time in patients with DRF. Results showed that Ghost has greater efficacy for improving wrist RoM in DRF patients than vibration alone. Treatment with Ghost can result in good RoM improvement during the acute phase of DRF in young patients and those with and normal or low body mass index. Further study is needed to verify our findings and assess the extent of RoM recovery.

Effectiveness of workplace exercise interventions in the treatment of musculoskeletal disorders in office workers: a systematic review

OBJECTIVE

To determine the effectiveness of workplace exercise interventions in the treatment of musculoskeletal disorders.

DESIGN

Systematic review of randomised controlled trials (RCTs).

DATA SOURCES

The bibliographical databases PubMed, CINAHL Plus, Cochrane, Scopus, ISI WoS and PeDRO were searched, with studies from 1 January 2010 to 31 December 2020 eligible for inclusion.

ELIGIBILITY CRITERIA

We included RCTs, reported in English or Spanish, with at least an intervention group performing workplace exercises among office workers with musculoskeletal disorders.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data and assessed the risk of bias. A narrative synthesis was carried out with a tabular method specifying the study characteristics following the SWiM (Synthesis Without Meta-Analysis) guideline for synthesis without meta-analysis. The revised Cochrane Risk of Bias (RoB-2) tool was used to analyse the risk of bias of the included studies.

RESULTS

Seven studies with a total of 967 participants met the inclusion criteria and were included in this review. Due to heterogeneity in different workplace exercise interventions, outcome measures and statistical analyses, it was not possible to conduct a meta-analysis and a narrative synthesis was performed. The interventions were classified into three categories: multiple body regions, neck and shoulder, and lower back. The seven studies concluded that workplace exercise interventions were effective in reducing musculoskeletal disorders and pain compared with other types of interventions or with control groups with no interventions. The RoB-2 tool found a high risk of bias in six of the seven studies.

CONCLUSIONS

The findings of the RCTs on workplace exercise interventions suggest that interventions were effective in treating musculoskeletal disorders among office workers. However, due to the high risk of bias of the included studies, no firm conclusions could be drawn and more high-quality studies are needed.

PROSPERO REGISTRATION NUMBER

CRD42020177462.

Healthcare and Scientific Treatment of Knee Osteoarthritis

Knee osteoarthritis is a chronic degenerative disease companied with chronic knee pain and dysfunction. However, the etiology and pathogenesis of knee osteoarthritis were unclear. Currently, age, diet, trauma, obesity, and inheritance are the main risk factors. The major pathological hallmarks of knee osteoarthritis included subchondral bone sclerosis, articular cartilage degeneration, arthrosynovitis, and osteophyte. With the acceleration of the aging process in China, the treatment of knee arthritis and the methods to improve the quality of life have become the focus of medical staff. Currently, therapies in clinical practice include surgery and nonoperative treatment; however, the clinical effects of different individuals at different stages will still be very different. This article reviews the recent advances in the treatment of knee osteoarthritis from three aspects: nonsurgical treatment, surgical treatment, and modern new medical means.

Pain and executive function: no association between remote exercise-induced hypoalgesia and cognitive inhibition in pain-free participants

OBJECTIVES

Cognitive inhibition, which denotes the ability to suppress predominant or automatic responses, has been associated with lower pain sensitivity and larger conditioned pain modulation in humans. Studies exploring the association between cognitive inhibition and other pain inhibitory phenomena, like exercise-induced hypoalgesia (EIH), are scarce. The primary aim was to explore the association between cognitive inhibition and EIH at exercising (local) and non-exercising (remote) muscles after isometric exercise. The secondary aim was to explore the association between cognitive inhibition and pressure pain sensitivity.

METHODS

Sixty-six pain-free participants (28.3 ± 8.9 years old, 34 women) completed two cognitive inhibition tasks (stop-signal task and Stroop Colour-Word task), a 3-min isometric wall squat exercise, and a quiet rest control condition with pre- and post-assessments of manual pressure pain thresholds at a local (thigh) and a remote site (shoulder). In addition, cuff pressure pain thresholds, pain tolerance and temporal summation of pain were assessed at baseline.

RESULTS

No association was found between remote EIH and cognitive inhibition (Stroop interference score: r=0.12, [-0.15; 0.37], p=0.405, BF01=6.70; stop-signal reaction time: r=-0.08, [-0.32; 0.17], p=0.524, BF01=8.32). Unexpectedly, individuals with worse performance on the Stroop task, as indicated by a higher Stroop interference score, showed higher local EIH (r=0.33; [0.10; 0.53], p=0.007, BF01=0.29). No associations were observed between pain sensitivity and any of the cognitive inhibition performance parameters.

CONCLUSIONS

The present findings do not support previous evidence on positive associations between exercise-induced hypoalgesia and cognitive inhibition, as well as baseline pain sensitivity and cognitive inhibition.

Voluntary running attenuates behavioural signs of low back pain: dimorphic regulation of intervertebral disc inflammation in male and female SPARC-null mice

OBJECTIVE

To examine the effect of running exercise on behavioral measures of pain and intervertebral disc (IVD) inflammation in the SPARC-null mouse model.

METHODS

Male and female 8-month old SPARC-null and age-matched control mice received a home cage running wheel or a control, fixed wheel for 6 months. Behavioral assays were performed to assess axial discomfort (grip test) and radiating leg pain (von Frey, acetone tests) and voluntary running was confirmed. Expression of inflammatory mediators (TNF-α, IL-1β, IL-2, IL-10, CCL5, CXCL1, CXCL5, RANKL, M-CSF, and VEGF) in IVDs was determined. Additional inflammatory (IL-1β, IL-1Ra, CXCR1, CXCR2) and macrophage phenotypic markers (ITGAM, CD80, CD86, CD206, Arg1) in IVDs were investigated by qPCR.

RESULTS

Voluntary running attenuated behavioral measures of pain in male and female SPARC-null mice. Increases in mediators including IL-1β, CXCL1 and CXCL5 were observed in SPARC-null compared to control IVDs. After 6 months of running, increases in M-CSF and VEGF were observed in male SPARC-null IVDs. In females, pro-inflammatory mediators, including CXCL1 and CXCL5 were downregulated by running in SPARC-null mice. qPCR analysis further confirmed the anti-inflammatory effect of running in female IVDs with increased IL-1Ra mRNA. Running induced upregulation of the macrophage marker ITGAM mRNA in males.

CONCLUSIONS

Voluntary running reversed behavioral signs of pain in male and female mice and reduced inflammatory mediators in females, but not males. Thus, the therapeutic mechanism of action may be sex-specific.

Specific versus Non-Specific Exercises for Chronic Neck or Shoulder Pain: A Systematic Review

The current systematic review aimed to compare the effect of injury-focused (specific) exercises versus more general (non-specific) exercises on pain in patients with chronic neck or shoulder pain. We searched PubMed, EMBASE, and Web of Science. Two reviewers screened and selected studies, extracted outcomes, assessed risk of bias, and rated the quality of evidence. A total of nine eligible studies, represented in 13 articles, were identified, with a considerable risk of bias. One article investigated the acute effect of single bouts of exercise on pain and reported an immediate pain reduction after non-specific exercise. Regarding short-term effects, seven out of the nine studies found no differences in pain between interventions, with inconsistent results among two other studies. Concerning the long-term effects, while pain reduction seems to be favored by specific exercises (two out of four articles), the best format is still unclear. Based on the acute effects, a single bout of non-specific exercise seems to be a better option for pain-relief for patients with chronic neck or shoulder pain. For short-term effects, there are no differences in pain between specific and non-specific exercises. Regarding long-term effects, specific exercises seem to be the best option. Nevertheless, more studies are warranted.

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.

Virtual Mind-Body Program for Obese Knee Osteoarthritis Patients with Comorbid Depression: Development and Feasibility Pilot (Preprint)

Background

Knee osteoarthritis (KOA) is the most common joint disorder in the United States and a leading cause of disability. Depression and obesity are highly comorbid with KOA and accelerate knee degeneration and disability through biopsychosocial mechanisms. Mind-body physical activity programs can engage biological, mechanical, and psychological mechanisms to improve outcomes in KOA, but such programs are not currently available.

Objective

This mixed methods study aims to adapt a mind-body activity program for the unique needs of patients with KOA, depression, and obesity (GetActive-OA) delivered via live video.

Methods

Participants were adults (aged ≥45 years) from rural Kentucky with obesity (BMI≥30 kg/m²), idiopathic KOA with mild to moderate radiographic changes, and elevated depressive symptoms (9-item Patient Health Questionnaire ≥10) recruited from 2 orthopedic centers. In phase 1, we developed GetActive-OA and the study protocol using qualitative focus group feedback from the study population (N=9; 2 focus groups, 90 minutes) and multidisciplinary expertise from clinical psychologists and orthopedic researchers. In phase 2, we explored the initial feasibility, credibility, and acceptability of GetActive-OA, live video delivery, and study procedures via an open pilot with exit interviews (N=5; 1 group). This research was guided by National Institutes of Health (NIH) model stage IA.

Results

Phase 1 qualitative analyses revealed nuanced information about challenges with coping and increasing activity, high interest in a mind-body activity program, program participation facilitators (flexibility with technology) and barriers (amotivation and forgetfulness), and perceived challenges with data collection procedures (blood and urine samples and homework). Phase 2 quantitative analyses showed that GetActive-OA met most a priori feasibility markers: acceptability (80%), expectancy (100%), credibility (100%), clinician adherence (90%), homework adherence (80%), questionnaire data collection (100%), program satisfaction (100%), and safety (100%). Adherence to ActiGraph wear (80% baseline, 20% posttest) and collection of blood samples (60%) were low. Participation in GetActive-OA was associated with signals of improvements in general coping (Cohen d=2.41), pain catastrophizing (Cohen d=1.24), depression (Cohen d=0.88), anxiety (Cohen d=0.78), self-efficacy (Cohen d=0.73), pain (Cohen d=0.39), and KOA symptoms (Cohen d=0.36). Qualitative exit interviews confirmed quantitative findings and provided valuable information to optimize the program and protocol.

Conclusions

Patients with KOA, depression, and obesity from rural Kentucky were interested in a live video mind-body activity program. GetActive-OA shows promise; however, the program and protocol require further NIH stage I refinement before formal efficacy testing (NIH model stage II).

International Registered Report Identifier (IRRID)

RR2-10.1016/j.conctc.2021.100720

Obesity Hurts: The Why and How of Integrating Weight Reduction With Chronic Pain Management

Amongst adults with chronic pain, overweight and obesity are highly prevalent. The association between chronic pain and overweight is driven by several explanations, including increased biomechanical load, changes in the gut microbiome, and low-grade (neuro)inflammation. Moreover, the link between overweight, obesity and chronic pain can best be considered from a lifestyle perspective. Since conservative treatment for chronic pain is often limited to short-term and small effects, addressing important comorbidities within a lifestyle approach could be the next step towards precision medicine for these patients. Indeed, evidence shows that combining weight reduction with conservative pain management is more effective to reduce pain and disability, compared to either intervention alone. This perspective article aims to update the reader with the current understanding of the possible explanatory mechanisms behind the interaction between overweight/obesity and chronic pain in an adult population. Second, this paper applies this knowledge to clinical practice, including assessment and conservative treatment of overweight/obesity in adults with chronic pain. Henceforth, clinical recommendations and guidelines are provided based on available scientific evidence and the authors' clinical expertise.

IMPACT

This paper will guide clinicians in the implementation of weight reduction programs within pain management.

Active heel-slide exercise therapy facilitates the functional and proprioceptive enhancement following total knee arthroplasty compared to continuous passive motion

PURPOSE

The aim was to compare active heel-slide exercise (AHSE) + standard physiotherapy (PT) to continuous passive motion (CPM) + standard PT during inpatient rehabilitation of total knee arthroplasty (TKA) patients in terms of postoperative outcomes.

METHODS

Patients were randomly assigned into AHSE or CPM groups. Both groups received standard PT (range of motion and strengthening exercises, and ambulation) during hospital stay. Patients were evaluated regarding functional outcomes, knee proprioception, pain intensity, active range of motion, knee circumference, length of hospital stay, time for achieving straight leg raise actively, time for achieving 70° knee flexion.

RESULTS

Groups were similar at baseline (n.s.). At discharge, AHSE group was better in terms of pain intensity (p < 0.001), Hospital for Special Surgery knee score (p = 0.001), rise from sitting (p = 0.015), ascend/descend stairs (p = 0.038), and timed up and go test (p = 0.028) compared to CPM group. AHSE group was able to perform the straight leg raise earlier than CPM group during inpatient period (p = 0.001) and demonstrated improved proprioception at discharge and at 3-month follow-up (p < 0.05). No statistical differences were detected between groups in other evaluation parameters (n.s.).

CONCLUSION

Our findings support AHSE therapy offers a more functional rehabilitation and leads beneficial results for patients following TKA. Therefore, active exercise approach encouraging patients to participate in their rehabilitation should be first choice in acute postoperative rehabilitation following TKA rather than CPM.

LEVEL OF EVIDENCE

II.

The Prospective Prognostic Value of Biopsychosocial Indices of Sensitivity to Physical Activity Among People With Back Pain

OBJECTIVES

Many people living with musculoskeletal pain conditions experience a range of negative biopsychosocial responses to physical activity, referred to as increased sensitivity to physical activity (SPA), that may undermine successful rehabilitation. This exploratory study aims to provide the first prospective analysis of the potential prognostic value of 3 biopsychosocial indices of SPA in relation to rehabilitation outcomes. This study also aimed to shed light on the cross-sectional interrelationships between these 3 biopsychosocial indices of SPA.

MATERIALS AND METHODS

Adults with back pain were evaluated upon starting physical therapy and then again 3 months later. The initial testing session consisted of self-reported pain-related questionnaires and assessment of activity-related changes in pressure pain thresholds (SPA-Sensory), pain intensity ratings (SPA-Pain), and situational catastrophizing (SPA-Psych). The 3-month follow-up consisted of self-reported disability and pain questionnaires. Correlational and hierarchical linear regression analyses were conducted.

RESULTS

A total of 97 participants completed both the initial visit and 3-month follow-up. The SPA-Pain index and the SPA-Psych index were significantly intercorrelated, but neither were correlated with the SPA-Sensory index. The SPA-Sensory index was not correlated with outcomes. The SPA-Pain index was correlated only with cross-sectional disability and pain outcomes. The SPA-Psych index was the only SPA index significantly correlated with outcomes both cross-sectionally and at 3-month follow-up. After controlling for baseline pain/disability and pain catastrophizing, SPA-Psych was no longer a significant prognostic factor for pain, but remained a significant prognostic factor for disability at 3-month follow-up (β=0.272, t=2.674, P=0.008, R2 Δ=5.60%).

DISCUSSION

This study highlights the importance of conceptualizing and measuring SPA as a biopsychosocial (rather than unidimensional) construct and points toward the added prognostic value of this construct. Implications for future research and practice are discussed.

A qualitative investigation of activity measurement and change following a mind-body activity program for chronic pain

Increasing activity is important yet challenging among people with chronic pain. Objective assessment of activity using accelerometers (i.e., ActiGraph) has gained popularity, but reactivity to assessment and non-adherence to wearing the ActiGraph may bias data. We explored: 1) experiences of wearing the ActiGraph to identify ways to increase adherence and facilitate accurate assessment of activity; and 2) barriers and facilitators to increasing activity following two mind-body activity programs to optimize future interventions. We conducted semi-structured exit interviews with 13 participants with heterogenous chronic pain who completed a randomized controlled trial of two mind-body activity programs. We analyzed transcripts using a framework approach to generate themes. Participants indicated that receiving reminders increased ActiGraph wear adherence and reported that program skills such as gratitude, pacing, mindfulness, and deep breathing were facilitators to increasing activity, while medical problems were barriers. Interventions aiming to increase activity may benefit from emphasizing mind-body skills and sending ActiGraph wear reminders.

Motor Control Exercises Compared to Strengthening Exercises for Upper- and Lower-Extremity Musculoskeletal Disorders: A Systematic Review With Meta-Analyses of Randomized Controlled Trials

OBJECTIVE

The purpose of this review was to compare the efficacy of motor control exercises (MCEs) to strengthening exercises for adults with upper- or lower-extremity musculoskeletal disorders (MSKDs).

METHODS

Electronic searches were conducted up to April 2020 in Medline, Embase, Cochrane CENTRAL, and CINAHL. Randomized controlled trials were identified on the efficacy of MCEs compared to strengthening exercises for adults with upper- or lower-extremity MSKDs. Data were extracted with a standardized form that documented the study characteristics and results. For pain and disability outcomes, pooled mean differences (MDs) and standardized mean differences (SMDs) were calculated using random-effects inverse variance models.

RESULTS

Twenty-one randomized controlled trials (n = 1244 participants) were included. Based on moderate-quality evidence, MCEs lead to greater pain (MD = -0.41 out of 10 points; 95% CI = -0.72 to -0.10; n = 626) and disability reductions (SMD = -0.28; 95% CI = -0.43 to -0.13; n = 713) when compared to strengthening exercises in the short term; these differences are not clinically important. When excluding trials on osteoarthritis (OA) participants and evaluating only the trials involving participants with rotator cuff-related shoulder pain, shoulder instability, hip-related groin pain, or patellofemoral pain syndrome, there is moderate quality evidence that MCEs lead to greater pain (MD = -0.74 out of 10 points; 95% CI = -1.22 to -0.26; n = 293) and disability reductions (SMD = -0.40; 95% CI = -0.61 to -0.19; n = 354) than strengthening exercises in the short term; these differences might be clinically important.

CONCLUSIONS

MCEs lead to statistically greater pain and disability reductions when compared to strengthening exercises among adults with MSKDs in the short term, but these effects might be clinically important only in conditions that do not involve OA. Inclusion of new trials might modify these conclusions.

IMPACT

These results suggest that MCEs could be prioritized over strengthening exercises for adults with the included non-OA MSKDs; however, results are unclear for OA disorders.

Are endogenous opioid mechanisms involved in the effects of aerobic exercise training on chronic low back pain? A randomized controlled trial

Aerobic exercise is believed to be an effective chronic low back pain (CLBP) intervention, although its mechanisms remain largely untested. This study evaluated whether endogenous opioid (EO) mechanisms contributed to the analgesic effects of an aerobic exercise intervention for CLBP. Individuals with CLBP were randomized to a 6-week, 18-session aerobic exercise intervention (n = 38) or usual activity control (n = 44). Before and after the intervention, participants underwent separate laboratory sessions to assess responses to evoked heat pain after receiving saline placebo or intravenous naloxone (opioid antagonist) in a double-blinded, crossover fashion. Chronic pain intensity and interference were assessed before and after the intervention. Endogenous opioid analgesia was indexed by naloxone-placebo condition differences in evoked pain responses (blockade effects). Relative to controls, exercise participants reported significantly greater pre-post intervention decreases in chronic pain intensity and interference (Ps < 0.04) and larger reductions in placebo condition evoked pain responsiveness (McGill Pain Questionnaire-Short Form [MPQ]-Total). At the group level, EO analgesia (MPQ-Total blockade effects) increased significantly pre-post intervention only among female exercisers (P = 0.03). Dose-response effects were suggested by a significant positive association in the exercise group between exercise intensity (based on meeting heart rate targets) and EO increases (MPQ-Present Pain Intensity; P = 0.04). Enhanced EO analgesia (MPQ-Total) was associated with a significantly greater improvement in average chronic pain intensity (P = 0.009). Aerobic exercise training in the absence of other interventions appears effective for CLBP management. Aerobic exercise-related enhancements in endogenous pain inhibition, in part EO-related, likely contribute to these benefits.