Uncovering emotional and network dynamics in the speech of patients with chronic low back pain

BACKGROUND

Computational linguistics allows an understanding of language structure and different forms of expression of patients' perceptions.

AIMS

The aims of this study were (i) to carry out a descriptive analysis of the discourse of people with chronic low back pain using sentiment analysis (SA) and network analysis; (ii) to verify the correlation between patients' profiles, pain intensity and disability levels with SA and network analysis; and (iii) to identify clusters in our sample according to language and SA using an unsupervised machine learning technique.

METHODS

We performed a secondary analysis of a qualitative study including participants with chronic non-specific low back pain. We used the data related to participants' feelings when they received the diagnosis. The SA and network analysis were performed using the Valence Aware Dictionary and sEntiment Reasoner, and the Speech Graph, respectively. Clustering was performed using the K-means algorithm.

RESULTS

In the SA, the mean composite score was -0.31 (Sd. = 0.58). Most participants presented a negative discourse (n = 41; 72%). Word Count (WC) and Largest Strongly connected Component (LSC) positively correlated with education. No statistically significant correlations were observed between pain intensity, disability levels, SA, and network analysis. Two clusters were identified in our sample.

CONCLUSION

The SA showed that participants reported their feeling when describing the moment of the diagnosis using sentences with negative discourse. We did not find a statistically significant correlation between pain intensity, disability levels, SA, and network analysis. Education level presented positive correlation with WC and LSC.

Are we missing the opioid consumption in low- and middle-income countries?

OBJECTIVES

The rise in opioid prescriptions with a parallel increase in opioid use disorders remains a significant challenge in some developed countries (opioid epidemic). However, little is known about opioid consumption in low- and middle-income countries (LMICs). In this short report, we aim to discuss the increase in opioid consumption in LMICs by providing an update on the opioid perspective in Brazil.

METHODS

We analyzed opioid sales on the publicly available Brazilian Health Regulatory Agency (ANVISA) database from 2015 to 2020.

RESULTS

In Brazil, opioid sales increased 34.8 %, from 8,839,029 prescriptions in 2015 to 11,913,823 prescriptions in 2020, this represents an increase from 44 to 56 prescriptions for every 1,000 inhabitants. Codeine phosphate combined with paracetamol and tramadol hydrochloride were the most common opioids prescribed with an increase each year.

CONCLUSIONS

The results suggest that opioid prescriptions are rising in Brazil in a 5 years period. Brazil may have a unique opportunity to learn from other countries and develop consistent policies and guidelines to better educate patients and prescribers and to prevent an opioid crisis.

Effectiveness of Cognitive Functional Therapy Versus Core Exercises and Manual Therapy in Patients With Chronic Low Back Pain After Spinal Surgery: Randomized Controlled Trial

OBJECTIVE

Our aim was to investigate whether cognitive functional therapy (CFT) was more effective than core exercises and manual therapy (CORE-MT) in improving pain and function for patients with chronic low back pain after spinal surgery.

METHODS

This study was a randomized controlled superiority trial in a university hospital and a private physical therapist clinic in Santa Catarina, Brazil. Eighty participants who were 18 to 75 years old and had chronic low back pain after spinal surgery received 4 to 12 treatment sessions of CFT or CORE-MT once per week for a maximum period of 12 weeks. Primary outcomes were pain intensity (numeric pain rating scale, scored from 0 to 10) and function (Patient-Specific Functional Scale, scored from 0 to 10) after intervention.

RESULTS

We obtained primary outcome data for 75 participants (93.7%). CFT was more effective, with a large effect size, than CORE-MT in reducing pain intensity (mean difference [MD] = 2.42; 95% CI = 1.69-3.14; effect size [d] = 0.85) and improving function (MD = -2.47; 95% CI = -3.08 to -1.87; effect size = 0.95) after intervention (mean = 10.4 weeks [standard deviation = 2.17] after the beginning of treatment). The differences were maintained at 22 weeks for pain intensity (MD = 1.64; 95% CI = 0.98-2.3; effect size = 0.68) and function (MD = -2.01; 95% CI = -2.6 to -1.41; effect size = 0.81).

CONCLUSION

CFT was more effective than CORE-MT, with large effect sizes, and may be an option for patients with chronic low back pain after spinal surgery.

IMPACT

CFT reduces pain and improves function, with large effect sizes, compared with CORE-MT. The difference between CFT and CORE-MT was sustained at the midterm follow-up. Treatment with CFT may be an option for patients with chronic low back pain after spinal surgery.

What are Brazilian orthopaedists' views on the diagnosis and treatment of patients with chronic nonspecific low back pain? A qualitative investigation

BACKGROUND

Orthopaedists are often the first point of contact for patients who present with low back pain (LBP) and chronic LBP in Brazil.

AIM

To explore the views of orthopaedists on therapeutic approaches for chronic non-specific low back pain (CNLBP) with a view to gain insights into aspects of clinical practice considered important to them.

METHODS

A qualitative design underpinned by interpretivism was employed. Participants were (n = 13) orthopaedists with experience in treating patients with CNLBP. Following the pilot interviews, semi-structured interviews were conducted, audio-recorded, transcribed and de-identified. Interview data were thematically analysed.

RESULTS

Four themes were identified. (1) Biophysical aspects are important and predominate, but sometimes their relevance can be unclear; (2) Psychosocial aspects and lifestyle factors influence the therapeutic approach; (3) Treatment of CNLBP - including medication, physical activity, surgery and other invasive procedures and other therapeutic modalities; and (4) Nuances of clinical practice - "it goes beyond medicine".

CONCLUSION

Brazilian orthopaedists value identifying the biophysical cause(s) of chronic low back pain. Psychological factors were often discussed secondary to biophysical aspects, whereas social aspects were rarely mentioned. Orthopaedists highlighted their difficulties in navigating patients' emotions and reassuring patients without referrals to imaging tests. Orthopaedists may benefit from training that targets communication and other relational aspects of care in order to work with people who present with CNLBP.

Defining text neck: a scoping review

BACKGROUND

Text neck is regarded as a global epidemic. Yet, there is a lack of consensus concerning the definitions of text neck which challenges researchers and clinicians alike.

PURPOSE

To investigate how text neck is defined in peer-reviewed articles.

METHODS

We conducted a scoping review to identify all articles using the terms "text neck" or "tech neck." Embase, Medline, CINAHL, PubMed and Web of Science were searched from inception to 30 April 2022. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMAScR) guidelines. No limitation was applied for language or study design. Data extraction included study characteristics and the primary outcome relating to text neck definitions.

RESULTS

Forty-one articles were included. Text neck definitions varied across studies. The most frequent components of definitions were grouped into five basis for definition: Posture (n = 38; 92.7%), with qualifying adjectives meaning incorrect posture (n = 23; 56.1%) and posture without a qualifying adjective (n = 15; 36.6%); Overuse (n = 26; 63.4%); Mechanical stress or tensions (n = 17; 41.4%); Musculoskeletal symptoms (n = 15; 36.6%) and; Tissue damage (n = 7; 17.1%).

CONCLUSION

This study showed that posture is the defining characteristic of text neck in the academic literature. For research purposes, it seems that text neck is a habit of texting on the smartphone in a flexed neck position. Since there is no scientific evidence linking text neck with neck pain regardless of the definition used, adjectives like inappropriate or incorrect should be avoided when intended to qualify posture.

Better Work Ability Is Associated With Lower Levels of Both Occupational Stress and Occupational Physical Activity in Professional Drivers: A Cross-sectional Study

OBJECTIVE

The aim of the study is to investigate the association of sociodemographic factors, lifestyle, work organization, and professional profile with work ability in professional drivers.

METHODS

This is a cross-sectional study with 449 drivers in Curitiba, Paraná (Brazil). Participants were assessed regarding their work ability (Work Ability Index [WAI]), sociodemographic, lifestyle (physical activity [Baecke's questionnaire] and stress [Work Stress Scale]), work organization, and professional profile using self-completion instruments. The association of WAI with sociodemographic factors, lifestyle, work organization, and professional profile was determined by multivariable ordinal logistic regression models.

RESULTS

Lifestyle factors best explained the WAI variability. The WAI was inversely associated with stress and occupational physical activities but directly associated with leisure activities and locomotion and leisure-time physical exercise.

CONCLUSIONS

Our data also challenge the concept that sociodemographic information and ergonomics organization influence determining the work ability of this population.

Exploratory analysis of 5 supervised machine learning models for predicting the efficacy of the endogenous pain inhibitory pathway in patients with musculoskeletal pain

OBJECTIVES

The identification of factors that influence the efficacy of endogenous pain inhibitory pathways remains challenging due to different protocols and populations. We explored five machine learning (ML) models to estimate the Conditioned Pain Modulation (CPM) efficacy.

DESIGN

Exploratory, cross-sectional design.

SETTING AND PARTICIPANTS

This study was conducted in an outpatient setting and included 311 patients with musculoskeletal pain.

METHODS

Data collection included sociodemographic, lifestyle, and clinical characteristics. CPM efficacy was calculated by comparing the pressure pain thresholds before and after patients submerged their non-dominant hand in a bucket of cold water (cold-pressure test) (1-4 °C). We developed five ML models: decision tree, random forest, gradient-boosted trees, logistic regression, and support vector machine.

MAIN OUTCOME MEASURES

Model performance were assessed using receiver operating characteristic curve (AUC), accuracy, sensitivity, specificity, precision, recall, F1-score, and the Matthews Correlation Coefficient (MCC). To interpret and explain the predictions, we used SHapley Additive explanation values and Local Interpretable Model-Agnostic Explanations.

RESULTS

The XGBoost model presented the highest performance with an accuracy of 0.81 (95% CI = 0.73 to 0.89), F1 score of 0.80 (95% CI = 0.74 to 0.87), AUC of 0.81 (95% CI: 0.74 to 0.88), MCC of 0.61, and Kappa of 0.61. The model was influenced by duration of pain, fatigue, physical activity, and the number of painful areas.

CONCLUSIONS

XGBoost showed potential in predicting the CPM efficacy in patients with musculoskeletal pain on our dataset. Further research is needed to ensure the external validity and clinical utility of this model.

Education to keep the abdomen relaxed versus contracted during pilates in patients with chronic low back pain: study protocol for a randomised controlled trial

BACKGROUND

Low back pain is a very common symptom frequently characterized as a biopsychosocial problem. This study aims to investigate the effectiveness of education to keep the abdomen relaxed versus contracted during Pilates exercises in patients with primary chronic low back pain.

METHODS

Two-group randomised controlled trial with allocation of parallel groups and intention-to-treat-analysis. This study will be conducted in Lavras, MG, Brazil. A total of 152 participants will be randomised into two groups that will be treated with Pilates exercises for 12 weeks (twice a week for 60 minutes). Recruitment began in May 2022. The control group will receive guidance on the specific activation of the center of strength (the powerhouse), while the experimental group will receive guidance to perform the exercises in a relaxed and smooth way. Primary outcomes will be pain intensity (Numeric Pain Rating Scale) and disability (Rolland-Morris Questionnaire) 12 weeks post randomisation. Secondary outcomes will be global improvement (Perception of Global Effect Scale) and specific functionality (Patient-specific Functional Scale). The outcomes will be analyzed using repeated-measure linear mixed models. The assessors were not considered blinded because the participants were not blinded, and outcomes were self-reported.

DISCUSSION

The findings of this study will help in clinical decision-making concerning the need to demand abdominal contraction during the exercises, understanding if it's a fundamental component for the effectiveness of the Pilates method for this population.

TRIAL REGISTRATION

This trial was prospectively registered in the Clinical Trials (NCT05336500) in April 2022.

Neural management plus advice to stay active on clinical measures and sciatic neurodynamic for patients with chronic sciatica: Study protocol for a controlled randomised clinical trial

Advice to stay active is the primary management strategy for sciatica. Other conservative treatments such as neural management techniques may also contribute to sciatica recovery, but currently, the effects have not been robustly assessed. Thus, the aim of this study is to compare the effects of adding neural management to advice to stay active versus advice to stay active alone in improving pain intensity and functional limitation. Secondarily, to compare the effects of the experimental intervention in the sciatic neurodynamic, pain modulation, and psychosocial factors. A parallel-group, controlled, examiner-blinded superiority clinical trial randomised at a 1:1 allocation will be conducted in 210 participants with chronic sciatica. Patients will be recruited from outpatient physiotherapy clinics and community advertisements. The experimental group will receive neural mobilisation techniques and soft tissue mobilisation techniques for 30 minutes per session, 10 weekly sessions, plus advice to stay active on their activities of daily living, information on physical activity, imaging tests, and sciatica for 5 biweekly sessions lasting 25-30 minutes. The control group will receive advice to stay active only. The re-evaluation will be performed out after 5 weeks, 10 weeks, and 26 weeks after randomisation and primary endpoints will be pain intensity and functional limitation at 10 weeks. Secondary outcomes will include neuropathic symptoms, sciatic neurodynamic, pain modulation, and psychosocial factors. Adverse events and patient satisfaction will be assessed. Ethical approval has been granted from an Institutional Human Research Ethics Committee. Trial registration: Trial was prospectively registered in the Brazilian Registry of Clinical Trials (number: RBR-3db643c).

Meditation for adults with non-specific low back pain: a systematic review and meta-analysis

OBJECTIVES

We aim to determine the effectiveness of meditation for adults with non-specific low back pain.

METHODS

We searched PubMed, EMBASE, PEDro, Scopus, Web of Science, Cochrane Library, and PsycINFO databases for randomized controlled trials that investigated the effectiveness of meditation in adults with non-specific low back pain. Two reviewers rated risk of bias using the PEDro scale and the certainty of the evidence using the GRADE approach. Primary outcomes were pain intensity and disability.

RESULTS

We included eight trials with a total of 1,234 participants. Moderate-certainty evidence shows that meditation is better than usual care for disability at short-term (SMD = -0.22; 95% CI = -0.42 to -0.02). We also found that meditation is better than usual care for pain intensity at long-term (SMD = -0.28; 95% CI = -0.54 to -0.02). There is no significant difference for pain intensity between meditation and minimal intervention or usual care at short and intermediate-term. We did not find differences between meditation and minimal intervention for disability at intermediate-term or usual care in any follow-up period.

CONCLUSIONS

We found small effect sizes and moderate-certainty evidence that meditation is slightly better than minimal intervention in the short-term for disability. Low-certainty of evidence suggests that meditation is slightly better than usual care for pain in the long-term. Meditation appears to be safe with most trials reporting no serious adverse events.

Consensus on evidence-based medicine curriculum contents for healthcare schools in Brazil

OBJECTIVES

Healthcare professionals need to take into account their knowledge, skills and attitudes to develop a focused clinical question, perform an effective search of the literature, critically appraise the evidence, and apply to the clinical context and evaluate the effectiveness of the process. To date, there is a lack of consensus on evidence-based medicine (EBM) curriculum for undergraduate healthcare students in Brazil. The aim of this study was to develop a consensus on EBM curriculum contents for healthcare schools in Brazil considering expert opinion.

DESIGN

Modified three-round Delphi methodology.

SETTING

Online survey.

PARTICIPANTS

The expert panel was composed of 40 healthcare professionals from different specialties. Most of the participants (n=24; 60%) were female with the age between 30 and 44 years. Participants were also experts in the field of epidemiology, biostatistics or public health. The mean experience of experts in teaching EBM was 9.5 years.

MAIN OUTCOME MEASURES

An online questionnaire consisting of 89 items related to EBM was sent to the experts. The experts ranked each item of EBM curriculum considering the importance of each item as omitted, mentioned, explained or practised. The last section of the questionnaire was composed of 'additional content' where the experts evaluated only if an item should be included or not, the form of offering the EBM contents and the total workload (in hours/semester). Open-ended questions were present in each section to give the opportunity to experts to insert suggestions. Items that reached values greater than or equal to 70% of agreement among experts was considered definitive for the curriculum. Items between 51% and 69% of agreement were included for the next round and those items with less than or equal to 50% of agreement were considered unnecessary and were excluded. In the third round, the EBM contents were classified according to the degree of consensus as follow: strong (≥70% of agreement), moderate (51%-69% of agreement) and weak (50% of agreement) based on the maximum consensus reached.

RESULTS

Of the 89 initial contents, 32 (35.9%) reached a strong degree of consensus, 23 (25.8%) moderate degree of consensus, two (2.2%) weak degree of consensus and 35 items were not recommended (≤50% of agreement). The workload suggested by experts should be between 61 and 90 hour/semester and an EBM curriculum should be offered with epidemiology and biostatistics as prerequisites. Regarding the importance of each item, 29 (72.5%) should be explained and 25 (27.5%) should be practised with exercises.

CONCLUSIONS

The consensus on an EBM curriculum for Brazilian healthcare schools consists of 54 items. This EBM curriculum also presents the degree of consensus (strong, moderate and weak), the importance of each item (mentioned, explained and practised with exercises). A total workload of between 60 and 90 hours per semester was suggested and the EBM curriculum should be offered with epidemiology and biostatistics as prerequisites, but also EBM contents should be included within other disciplines throughout the entire undergraduate course.

Self-Guided Web-Based Pain Education for People With Musculoskeletal Pain: A Systematic Review and Meta-Analysis

OBJECTIVE

The purpose of this study was to investigate the effectiveness of web-based pain education programs without clinical support in patients with musculoskeletal pain.

METHODS

PubMed, Scopus, CINAHL, Web of Science, Cochrane Library, and PsycINFO were searched from inception to February 2020. Included studies were randomized clinical trials in which people with musculoskeletal pain were allocated to an experimental group that received web-based pain education as a standalone approach. Three review authors performed data extraction. The PEDro (Physiotherapy Evidence Database) scale was used to assess the methodological quality of the studies. The primary outcomes were pain intensity and disability.

RESULTS

Six trials with a total of 1664 participants were included. There is moderate-quality evidence with a small effect size that web-based pain education programs, as a standalone approach, are better than minimal intervention (no intervention or booklets) for pain intensity (standardized mean difference [SMD] = -0.23; 95% CI = -0.43 to -0.04) in the short term and intermediate term (SMD = -0.26; 95% CI = -0.42 to -0.10). Regarding disability, there is low-quality evidence that web-based pain education programs are better than minimal intervention (SMD = -0.36; 95% CI = -0.64 to -0.07) in the short term. Web-based pain education added to usual care was no better than usual care alone in the intermediate or long term for primary outcomes.

CONCLUSIONS

Web-based pain education for adults with musculoskeletal pain, as a standalone approach, was better than minimal intervention for pain intensity and disability in the short term, and for pain intensity in the intermediate term. Web-based pain education added to usual care did not provide additional benefits for primary outcomes in the intermediate or long term.

IMPACT

Web-based pain education as a standalone intervention provided small improvements in pain intensity and disability in patients with chronic musculoskeletal pain. Poorly resourced settings and overburdened health systems should consider this delivery method in the management of chronic musculoskeletal pain.

LAY SUMMARY

If you have chronic musculoskeletal pain, your physical therapist might recommend web-based pain education as treatment to help you reduce pain intensity and disability.

'Your spine is so worn out' - the influence of clinical diagnosis on beliefs in patients with non-specific chronic low back pain - a qualitative study'

BACKGROUND

Patients' beliefs have an important influence on the clinical management of low back pain and healthcare professionals should be prepared to address these beliefs. There is still a gap in the literature about the influence of patients' perceptions of their clinical diagnosis on the severity of their pain experience and disability.

OBJECTIVES

To identify the perceptions of patients with chronic non-specific low back pain regarding the influence of their clinical diagnosis on pain, beliefs, and daily life activities.

METHODS

Qualitative study of 70 individuals with chronic non-specific low back pain. A semi structured interview was conducted about patients' beliefs and perceptions regarding the influence of clinical diagnosis on their daily activities and pain intensity.

RESULTS

Most participants believed that higher number of different clinical diagnoses for the same individual may be associated with high pain intensity and disability for daily activities and that pain and injury are directly related. Patients beliefs were grouped into four main themes: (1) pain has multifactorial explanation in physical dimension; (2) improvement expectation is extremely low in patients with chronic pain; (3) clinical diagnosis influences pain and disability levels; (4) clinical diagnosis is extremely valued by patients.

CONCLUSIONS

Patients believe that there is a strong relationship between structural changes in the lower back, pain, and daily life activities; thus, providing evidence of a strong influence of the biomedical model on their beliefs.

The challenging scenario of beliefs and attitudes toward chronic low back pain among final year undergraduate students: A cross-sectional investigation

OBJECTIVE

To identify the beliefs and attitudes of students in four health courses about chronic low back pain (CLBP) management, and to investigate personal and undergraduate training-related factors associated with their beliefs.

METHODS

Cross-sectional study conducted with 173 Brazilian medicine, physiotherapy, nursing and pharmacy students. Participants provided information on age, personal experience with LPB, training or class on CLBP management, and contact with patients with CLBP, followed by their first therapeutic choices. HC-PAIRS (0-90) was applied to understand the beliefs and attitudes related to CLBP. We built a One-Way ANOVA with Tukey post hoc tests to compare the results among courses. We built multivariate linear regression models to investigate associated factors with HC-PAIRS score.

RESULTS

Mean HC-PAIRS for all participants was 49.8 (±10.2). Physiotherapy students presented more positive CLBP beliefs compared to medicine, pharmacy and nursing students. Only 41.67% of the responses about the first therapeutic choices were according to the main guidelines of care for CLBP. Total HC-PAIRS score was positive and significantly associated with being a student from medicine, nursing and pharmacy.

CONCLUSION

Physiotherapy students had more positive beliefs about the association between pain and disability in those with CLBP. Still, the beliefs and attitudes of the majority of health students concerning CLBP are not yet in line with the current management framework.

"A journey to learn about pain": the development and validation of a comic book about pain neuroscience education for children

BACKGROUND

Pain education resources for children using appropriate language and illustrations remain scarce.

OBJECTIVES

We aimed to summarize the development process and testing for face and content validity of a structured comic book about pain education for children.

METHODS

A first draft of a comic book was developed (Portuguese and English) based on pain education concepts. Experts in pediatric pain from different countries analyzed content, objectives, language, illustrations, layout, motivation, and cultural adjustment. A third draft developed in Portuguese considering experts' suggestions was presented to children and parents in Brazil. The total adequacy score was calculated from the sum of the scores obtained in each domain, divided by the maximum total score. Descriptive analysis is presented.

RESULTS

The expert panel was composed of 11 (64.7%) physical therapists, and 6 (35.3%) psychologists. The total adequacy score (0-100%) was 87.74%. The third draft version of the comic book was presented to 28 children and the final version was presented to 16 children with a mean age of 9.6 years. Children were totally satisfied (n=4; 26.7%) or satisfied (n=9; 56.2%) with the story of the comic book. The readability of the comic book was considered suitable for grades 4 to 6 educational level.

CONCLUSION

The comic book "A Journey to Learn about Pain" was validated for face and content validity by the expert panel and the Brazilian target population. This comic book is available in Portuguese and English and can be a potentially useful resource for children.

Choosing Wisely Brazil: top 5 low-value practices that should be avoided in musculoskeletal physical therapy

BACKGROUND

The Choosing Wisely initiative aims to promote discussions among healthcare professionals and patients about low-value, or potentially harmful, health practices.

OBJECTIVES

To describe the process of development of the Brazilian Choosing Wisely list for musculoskeletal physical therapy.

METHODS

The Brazilian Choosing Wisely list was developed in accordance with the recommendations of the American Board of Internal Medicine. A three-step procedure was used. First, an expert panel was selected, and a modified Delphi approach was used to obtain a list of evidence-based statements. Second, members of the research team performed content analysis. Third, a national survey was conducted to present selected statements to a sample of physical therapists. Participants were invited to vote considering the level of importance of selected statements for physical therapists and patients.

RESULTS

The expert panel comprised 17 physical therapists. The median age of the expert panel was 33 [interquartile range (IQR) 29 to 37; range 26 to 60] years and the median length of professional experience was 12 (IQR 10 to 18) years. A list of eight recommendations was presented to a national sample composed of 1127 physical therapists. The median length of professional experience of the national sample was 10 (IQR 5 to 15) years. Based on the number of votes, the five most important recommendations were included in the Brazilian Choosing Wisely list for musculoskeletal physical therapy. Descriptive and frequency analysis were used to report the results.

CONCLUSION

The Brazilian Choosing Wisely list for musculoskeletal physical therapy provides an opportunity for physical therapists, patients, society and policy makers to collaboratively discuss tests and treatments that are unnecessary or potentially harmful.

Craniocervical Posture Assessed With Photogrammetry and the Accuracy of Palpation Methods for Locating the Seventh Cervical Spinous Process: A Cross-sectional Study

OBJECTIVE

The purpose of this study was to compare craniocervical posture assessed by photogrammetry using 2 distinct palpation methods for locating the spinous process of the seventh cervical vertebra (C7SP).

METHODS

This cross-sectional study was conducted in 2 phases. In phase I (n = 42), the assessor's accuracy in locating the C7SP using the flexion-extension and the modified thorax-rib static methods was compared to radiography. In phase II (n = 68), the craniocervical posture was analyzed with photogrammetry after palpation using the 2 methods. Neck pain intensity and disability were also determined.

RESULTS

The accuracy in locating the C7SP was higher using the modified thorax-rib static method (67%, 95% confidence interval [CI], 55-79) compared to the flexion-extension method (38%, 95% CI, 26-50, P = .016). Lower values of the craniocervical angle were obtained with the flexion-extension method than the modified thorax-rib static method (mean difference = -1.1°, 95% CI, -1.6 to -0.6, P < .001). However, both palpation methods resulted in similar classifications of participants as with or without forward head posture (P = .096). Weak correlations were observed between the craniocervical angle and neck pain intensity (ρ = -0.088 and -0.099, respectively) and disability (ρ = -0.231 and -0.249, respectively).

CONCLUSION

Craniocervical angles obtained using palpation methods with different accuracies were different, although the magnitude of the difference was insufficient to lead to different classifications of a forward head posture in adults with mild neck pain and disability. Craniocervical posture was weakly correlated with neck-pain intensity and disability.

Comparison of neck extensor muscle endurance and cervical proprioception between asymptomatic individuals and patients with chronic neck pain

INTRODUCTION

Neck extensor endurance (NEE) and cervical proprioception are vital for maintaining cervical spine function and defects in these processes have been associated with chronic neck pain (CNP). The objectives of the study are 1) To investigate the association between NEE and cervical joint position error (JPE) in subjects with CNP; 2) to compare the cervical extensor endurance and cervical JPE of CNP subjects with those of asymptomatic controls; and 3) to determine the relationship between Pain Catastrophizing Scale (PCS) scores, NEE, and cervical JPE in subjects with CNP.

METHOD

Sixty-four participants (32 asymptomatic, 32 with CNP) participated in this comparative cross-sectional study. Cervical proprioception was assessed by measuring the absolute JPE in the sagittal and transverse directions. NEE was assessed using a clinical extensor endurance test. NEE capacity and JPE were compared and correlated between asymptomatic and CNP subjects. Pain catastrophic behavior was assessed using the Pain Catastrophizing Scale (PCS) in CNP subjects.

RESULTS

CNP subjects showed lower NEE capacity (p < 0.001) and significantly larger JPEs (p < 0.001) than asymptomatic participants. NEE negatively correlated with JPEs in all directions (p < 0.001) in asymptomatic subjects and only neck extension errors showed a correlation in CNP subjects (r = -0.45, p = 0.009). PCS scores were negatively correlated with endurance capacity (r = -0.42, p = 0.017) and positively correlated with JPE (flexion: r = 0.57, p = 0.001).

CONCLUSION

CNP subjects showed impaired proprioception and lower endurance capacity compared to asymptomatic participants. Neck extension errors alone correlated with JPE in CNP subjects. PCS scores negatively correlated with NEE in subjects with CNP.

Cognitive functional therapy (CFT) compared with core training exercise (CTE) in patients with failed back surgery syndrome (FBSS): A study protocol for a randomized controlled trial

OBJECTIVE

This study aims to investigate the efficacy of cognitive functional therapy (CFT) compared to core training exercise (CTE) on pain and specific disability of patients with failed back surgery syndrome (FBSS).

DESIGN

This will be a randomized controlled clinical trial of two groups with blinded evaluators.

SETTING

The study will be conducted at the Federal University of Santa Catarina (UFSC) and a private clinic in Florianópolis, SC, Brazil.

PARTICIPANTS

A total of 80 participants, of both sexes, with FBSS.

INTERVENTION

Subjects will be randomized into two groups: one group receiving CFT or CTE. Individuals will be assisted once a week, for a maximum period of 12 weeks, with four being the minimum number of visits and 12 being the maximum number of visits.

MEASUREMENTS

The primary outcomes will be pain and specific disability.

CONCLUSIONS

This is the first study investigating whether CFT is efficacious for patients with FBSS and chronic low back pain. The study's sample size was calculated to detect the effect of clinically relevant treatment with a low risk of bias. This clinical trial was designed to be able to reproduce an approach as a physiotherapist trained in CFT would do. That is, in a pragmatic way, increasing the significance of this study. CTE comprises a strategy widely used by physiotherapists to treat low back pain. Given that the scientific evidence of its efficacy for pain management is limited, the findings of this study will assist physiotherapists in their clinical decision-making.

Overview of Curricula About Pain in Physical Therapist Education Programs in Brazil: A Faculty Survey

BACKGROUND

Educating health professionals about pain (pain education) during undergraduate studies may be an important step in changing ineffective pain management practices.

OBJECTIVE

The objective of this study was to assess the extent of pain education in current accredited physical therapist education programs in Brazil.

DESIGN

This study was designed as a cross-sectional survey study.

METHODS

Brazilian physical therapist education programs accredited by the Ministry of Education participated in this study. The main outcome measures were frequency of a specific curriculum about pain (pain curriculum) in physical therapist education programs and content analysis according to discipline-specific pain curriculum recommendations developed by the International Association for the Study of Pain.

RESULTS

A total of 811 physical therapist education programs in Brazil were identified. After duplicates and universities no longer offering a physical therapist education program were removed, a total of 566 physical therapist education programs were left; 399 of the 566 (70.5%) provided information about the curriculum on their websites. Among the identified physical therapist education programs with available curricula, 26 (6.5%) had a specific course about pain (pain course), covering a mean of 44.3 hours.

LIMITATIONS

Limitations included the inability to cover all the physical therapist education programs in Brazil and the inability to identify whether pain content is distributed in other disciplines such as pediatrics, geriatrics, and neurological and orthopedic physical therapy.

CONCLUSIONS

Most Brazilian physical therapist education programs do not offer a specific pain course. When a pain course is presented in the curriculum, some content recommended for physical therapist education programs by the International Association for the Study of Pain is not covered. The absence of a pain course in physical therapist education programs may have implications for pain management. To the best of our knowledge, this is the first study about pain education in physical therapist education programs in Brazil.

Trial Protocol: Cognitive functional therapy compared with combined manual therapy and motor control exercise for people with non-specific chronic low back pain: protocol for a randomised, controlled trial

INTRODUCTION

Chronic low back pain is a public health problem, and there is strong evidence that it is associated with a complex interaction of biopsychosocial factors. Cognitive functional therapy is an intervention that deals with potentially modifiable multidimensional aspects of pain (eg, provocative cognitive, movement and lifestyle behaviours). There is evidence (from a single randomised, controlled trial) that cognitive functional therapy is better than combined manual therapy and motor control exercise. However, this study had significant methodological shortcomings including the failure to carry out an intention-to-treat analysis and a considerable loss of follow-up of participants. It is important to replicate this study in another domain through a randomised clinical trial with similar objectives but correcting these methodological shortcomings.

AIM

To investigate the efficacy of cognitive functional therapy compared to combined manual therapy and exercise on pain and disability at 3 months in patients with chronic non-specific low back pain.

DESIGN

Two-group, randomised, multicentre controlled trial with blinded assessors.

PARTICIPANTS AND SETTINGS

One hundred and forty-eight participants with chronic low back pain that has persisted for >3months and no specific spinal pathology will be recruited from the school clinic of the Centro Universitário Augusto Motta and a private clinic in the city of Rio de Janeiro, Brazil.

INTERVENTION A

Four to 10 sessions of cognitive functional therapy. The physiotherapists who will treat the participants in the cognitive functional therapy group have previously attended 2 workshops with two different tutors of the method. Such physiotherapists have completed 106 hours of training, including workshops and patient examinations, as well as conducting a pilot study under the supervision of another physiotherapist with>3 years of clinical experience in cognitive functional therapy.

INTERVENTION B

Four to 10 sessions of combined manual therapy and motor control exercises. Participants in the combined manual therapy and exercise group will be treated by two physiotherapists with an average of >10years of clinical experience in manual therapy and motor control exercises, including isolated contractions of the deep abdominal muscles.

MEASUREMENTS

The primary outcome measures will be pain intensity and disability 3 months after randomisation. Secondary outcomes will be pain and disability assessed 6 and 12 months after randomisation, and both global perceived effect and patient satisfaction at 3, 6 and 12 months after randomisation. The potential outcome mediators will be assessed at 3 and 6 months after randomisation, with brief screening questions for anxiety, social isolation, catastrophisation, depression, fear of movement, stress and sleep. Non-specific predictors and moderators will include age, gender, duration of chronic low back pain, chronicity risk (Örebro and Start Back score), number of pain areas, stressful life event, MRI scan imaging, and family history.

ANALYSIS

Intention-to-treat analysis will be performed. Linear mixed models will be used to compare the mean differences in pain intensity, disability and global perceived effect between the intervention arms. The analysis of the effect of potential mediators of the treatment will be performed using the causal mediation methods described by Imai and colleagues. The baseline variables will be evaluated as predictors and moderators of treatment, including terms and interaction models. A level of statistical significance of 5% will be used in the analysis. All the analyses will be performed using RStudio.

SIGNIFICANCE

This study will investigate whether the results of the first cognitive functional therapy randomised clinical trial are reproducible. The present study will have a sample size capable of detecting clinically relevant effects of the treatment with a low risk of bias. In pragmatic terms, this clinical trial is designed to reproduce the intervention as it would be performed in clinical practice by a trained physiotherapist who works with cognitive functional therapy, which increases the relevance of this study. The combined manual therapy and exercise group comprises an intervention strategy widely used by physiotherapists to treat low back pain. As evidence of efficacy is still limited, the results of a randomised, controlled clinical trial of high methodological quality will help physiotherapists in clinical decision-making.

Association between pain drawing and psychological factors in musculoskeletal chronic pain: A systematic review

BACKGROUND

It has been speculated that there is an association between pain area and psychological factors in chronic musculoskeletal pain conditions; however, this relation is not well established.

PURPOSE

To investigate the association between pain distribution and psychological factors in chronic musculoskeletal pain conditions.

STUDY DESIGN

Systematic review.

METHODS

We searched the following databases using optimized search strategies: MEDLINE, PsycINFO, Scopus, Web of Science and Cochrane. Studies were included if they investigated the relation between pain area using a pain drawing (PD) and psychological factors measured by any consistent available method.

RESULTS

Eleven articles were included. A total of 1301 participants with different musculoskeletal pain conditions, including low back pain, whiplash-associated disorders and fibromyalgia took part in the studies. In three studies, the correlation between pain area and depression was weak (r = 0.15, p = N/A; r = 0.26, p < 0.05; r = 0.25, p = 0.01). Depression seemed to be a risk factor for pain in more body areas in one study (relative risk = 6.09, 95% CI = 1.1-33.5; p < 0.05). The relation between pain area and other psychological factors such as anxiety, kinesiophobia, catastrophizing, memory disturbances and concentration difficulties was also reported.

CONCLUSIONS

A definitive answer on the relation of psychological factors and pain area is not available; the findings suggest that only depression might have a weak relation with pain area. Future studies that investigate sensory, psychological, emotional, cognitive and behavioral aspects, and also more accurate methods of PD assessment, are needed.

Chronic low back pain and back muscle activity during functional tasks

There is evidence that patients with low back pain favor their trunk muscles when moving. However, it is unknown whether this maladaptive behavior is generalized across different functional tasks. This study analyzed the back muscle activity of patients with chronic low back pain compared to asymptomatic controls during five functional tasks. The secondary aim of this study was to test whether the electromyographic activity of patients' back muscles was correlated with either the TAMPA scale score or the Örebro Questionnaire. Forty patients with chronic, non-specific low back pain and 40 asymptomatic participants were assessed on the electromyographic activity of the lumbar longissimus, ilio-costal and multifidus while picking up and placing an object on the ground, sitting down and standing up, and climbing stairs. There was statistical evidence of two-way interactions involving group by task (F_4,308 = 7.921, p < 0.001, η² = 0.049) and task by muscle (F_18,1386 = 2.912, p < 0.001, η² = 0.004), but not group by muscle (F_7,539 = 1.104, p = 0.359, η² = 0.004). Patients with chronic low back pain showed an increase in back muscle activity regardless of the type of functional task, except the left side of multifidus muscle during the picking up of a ball on the ground task. There was no correlation between the measure of kinesiophobia or the Örebro questionnaire score and the level of electromyographic activity.

Association between home posture habits and neck pain in High School adolescents

BACKGROUND

Neck pain (NP) in adolescence is as frequent as in adulthood. However, the relationship between home posture habits and neck pain is still unknown.

OBJECTIVE

To investigate the prevalence of NP and the association with home posture habits (HPH) in adolescents.

METHODS

Cross-sectional study with High School adolescents. Students answered questions regarding sociodemographic variables, lifestyle, HPH (illustration in the questionnaire), time (TV, computer, video-game) and the presence of NP. Multivariate logistic regression was used to investigate the association between HPH and NP.

RESULTS

The prevalence of NP was 48.9%. The ones who watched TV lying supine in bed for 2 hours or more a day yielded an odds ratio (OR) of 6.21 (1.45-26.52) for acute neck pain (ANP). Who watched TV and used the desktop in the slump posture yielded, respectively, an OR of 4.0 (1.63-9.85), and 2.03 (1.23-3.34) for chronic neck pain (CNP). The ones who frequently changed their positions while using the desktop and used it for 2 hours or more a day yielded an OR of 0.34 (0.14-0.85) for ANP.

CONCLUSION

Our findings support the high prevalence of NP in adolescence and raise the association between some HPH and neck pain.