Article

Mechanisms-based classifications of musculoskeletal pain: Part 3 of 3: Symptoms and signs of nociceptive pain in patients with low back (+/- leg) pain

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Abstract

As a mechanisms-based classification of pain 'nociceptive pain' (NP) refers to pain attributable to the activation of the peripheral receptive terminals of primary afferent neurones in response to noxious chemical, mechanical or thermal stimuli. The symptoms and signs associated with clinical classifications of NP have not been extensively studied. The purpose of this study was to identify symptoms and signs associated with a clinical classification of NP in patients with low back (± leg) pain. Using a cross-sectional, between-subjects design; four hundred and sixty-four patients with low back (± leg) pain were assessed using a standardised assessment protocol after which their pain was assigned a mechanisms-based classification based on experienced clinical judgement. Clinicians then completed a clinical criteria checklist indicating the presence/absence of various symptoms and signs. A regression analysis identified a cluster of seven clinical criteria predictive of NP, including: 'Pain localised to the area of injury/dysfunction', 'Clear, proportionate mechanical/anatomical nature to aggravating and easing factors', 'Usually intermittent and sharp with movement/mechanical provocation; may be a more constant dull ache or throb at rest', and the absence of 'Pain in association with other dysesthesias', 'Night pain/disturbed sleep', 'Antalgic postures/movement patterns' and 'Pain variously described as burning, shooting, sharp or electric-shock-like'. This cluster was found to have high levels of classification accuracy (sensitivity 90.9%, 95% CI: 86.6-94.1; specificity 91.0%, 95% CI: 86.1-94.6). Pattern recognition of this empirically-derived cluster of symptoms and signs may help clinicians identify an assumed dominance of NP mechanisms in patients with low back pain disorders.

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... " 13 Given that no actual tissue damage is required for a patient to experience pain, there has been a push to identify the predominant pain mechanism in a patient presenting with pain versus working immediately to identify damaged tissue in such a patient. [14][15][16][17][18] Th ree predominant pain mechanisms have been identifi ed: nociceptive, neuropathic, and nociplastic pain. [15][16][17][18] Nociceptive pain is typically produced by activation of peripheral nociceptors and can be attributed to pathologic processes underlying injured tissues in the musculoskeletal system such as muscles, ligaments, vertebrae, intervertebral disks, and joints. ...
... [14][15][16][17][18] Th ree predominant pain mechanisms have been identifi ed: nociceptive, neuropathic, and nociplastic pain. [15][16][17][18] Nociceptive pain is typically produced by activation of peripheral nociceptors and can be attributed to pathologic processes underlying injured tissues in the musculoskeletal system such as muscles, ligaments, vertebrae, intervertebral disks, and joints. 18 Key elements of the clinical cluster of nociceptive pain include 1) pain localized to the area of dysfunction, 2) clear, proportionate mechanical aggravating and easing factors, 3) intermittent and sharp pain with movement or mechanical provocation, and 4) absence of neurologic symptoms. ...
... [15][16][17][18] Nociceptive pain is typically produced by activation of peripheral nociceptors and can be attributed to pathologic processes underlying injured tissues in the musculoskeletal system such as muscles, ligaments, vertebrae, intervertebral disks, and joints. 18 Key elements of the clinical cluster of nociceptive pain include 1) pain localized to the area of dysfunction, 2) clear, proportionate mechanical aggravating and easing factors, 3) intermittent and sharp pain with movement or mechanical provocation, and 4) absence of neurologic symptoms. 18 Neuropathic pain is due to various complex pathophysiologic processes of the nervous system, such as spinal nerve roots. ...
Article
Low back pain (LBP) continues to be one of the most common conditions leading patients to seek medical care globally. The NP is on the frontline, playing an integral role in caring for patients with LBP. Understanding the etiology of LBP is essential in the treatment.
... In many occasions, differentiating the various phenotypes clinically is difficult. Smart et al [11][12][13] proposed a mechanism-based classification to differentiate between different types of musculoskeletal LBP (central sensitisation, peripheral neuropathic and nociceptive). ...
... The percentage reduction in NRS pain at week 24 will also be evaluated according to various musculoskeletal CLBP subtypes based on pain mechanism (nociceptive vs peripheral neuropathic vs central sanitisation). [11][12][13] The secondary objectives are to evaluate the effects of PLFMF on (1) pain intensity during treatment and early after treatment completion, (2) level of disability, (3) functional levels, (4) sleep quality, (5) quality of life and (6) fatigue in patients with CLBP. The study will also investigate the long-term side effects of PLFMF. ...
... The 38-item clinical criteria checklist developed by Smart et al [11][12][13] will be used to classify patients into different phenotypes of musculoskeletal CLBP. This method of discriminative validity was established. ...
... Emerging pain science research at minimum divides pain into one of three categories: nociceptive driven pain states, peripheral neuropathic pain states and CS [24,25]. This subclassification of pain has been widely used, expanded upon, and has significant implications for assessment and treatment of patients attending PT [26][27][28][29]. A key tenant of this model is even more elementary: identifying patients with or without the clinical presence of CS. ...
... A clinical question, however, remains: how prevalent is CS in PT? Yes, chronic pain is very common, but not all patients with chronic pain present with CS. Some patients present with chronic nociceptive pain, where innervated tissues continue to be the main driver of the pain experience [26]. In others, the peripheral nervous system is the main driver, referred to as peripheral neuropathic pain [27]. ...
... The overall, mean CSI score was 26 the patients were classified as "low" in regard to CSI scores ( Figure 1). Nearly one in five patients (n = 39; 17.3%) were classified as "high" in regard to CSI scores. ...
Article
Study Design: Survey study. Objective: To determine what percentage of patients attending physical therapy with musculoskeletal pain present with central sensitization and which patient factors may be predictive of central sensitization. Background: Treating pain, especially chronic pain is clinically challenging. It has been suggested that pain be sub-classified as either nociceptive, peripheral neuropathic or central sensitization, to aid clinical decision-making to inform the treatment approach for specific pain conditions. Methods: A convenience sample of adult patients (18-65) attending PT for musculoskeletal pain were asked to complete a demographic questionnaire and the central sensitization inventory. Results: Two-hundred and forty-five patients completed the central sensitization inventory, resulting in a mean score of 26.88 ± 15.54. The majority of the patients were classified as “low” in regard to central sensitization scores and nearly one in five patients (n = 39; 17.3%) were classified as “high” in regard to central sensitization scores. The variables of ‘being disabled’ (β = 13.73), ‘currently experiencing feelings of depression’ (β = 9.35), and ‘identifying as female’ (β = 3.60), had the largest partial effects on central sensitization as individual variables. Conclusions: Approximately one in five patients attending PT for musculoskeletal pain present with a central sensitization inventory score of > 40, suggesting presence of central sensitization. Patients that reported feeling disabled, experiencing feelings of depression and ‘identifying as female’ were more likely to score > 40 on the central sensitization inventory. Central sensitization is relatively common in patients attending PT for musculoskeletal pain and various patient characteristics may suggest higher potential CSI scores at intake.
... A mechanism-based classification approach has been proposed by several different authors [17][18][19][20][21][22][23][24] as an alternative to the traditional temporal-based classification to better inform pain management interventions (see Chapter 96). As the name implies, this approach to classifying pain focuses on identifying the dominant neurophysiological mechanism that is driving the individual's pain experience. ...
... Within this framework, there are three predominant mechanisms: nociception dominant, peripheral neuropathic dominant, and nociplastic dominant (sometimes referred to as central sensitization dominant). [18][19][20]25 ...
... Patients traditionally classified as having chronic pain may have a nociception-dominant or peripheral neuropathic-dominant pain state rather than a nociplastic-dominant pain state. 18,20,22 To further complicate things, it is possible for individuals to present without one clear dominant driver-more of a mixed-driver presentation. 31 Although there remains no agreed upon gold standard test for the identification of nociplastic or central sensitization-dominant pain, the Delphi-derived clinical signs and symptoms 32 that have been shown to be most predictive of central sensitization-or nociplastic-dominant pain are listed in Box 94.3. ...
... Through this approach, they identified a mechanisms-based classification for musculoskeletal pain that included: 1) central sensitization; 34 2) peripheral neuropathic (radicular or referred), 35 and 3) nociceptive. 36 The ability to identify the predominant mechanism-based classification is reliable in patients with nonspecific cervical pain (kappa = .84 (95% CI: .65, ...
... Nociceptive pain is localized to an area of injury or dysfunction. 36 Provocation and/or alleviation are identifiable and proportionate, match known mechanical and anatomical distributions, symptoms are usually intermittent and start with the onset of movement or mechanical provocation. 36 The quality of symptoms may be a constant dull ache or a throb at rest. ...
... 36 Provocation and/or alleviation are identifiable and proportionate, match known mechanical and anatomical distributions, symptoms are usually intermittent and start with the onset of movement or mechanical provocation. 36 The quality of symptoms may be a constant dull ache or a throb at rest. 36 This group of patients should not have pain associated with other dysesthesias, night pain or disturbed sleep, and antalgic postures or movement patterns. ...
Article
Background There is considerable overlap between pain referral patterns from the lumbar disc, lumbar facets, the sacroiliac joint (SIJ), and the hip. Additionally, sciatic like symptoms may originate from the lumbar spine or secondary to extra-spinal sources such as deep gluteal syndrome (GPS). Given that there are several overlapping potential anatomic sources of symptoms that may be synchronous in patients that have low back pain (LBP), it may not be realistic that a linear deductive approach can be used to establish a diagnosis and direct treatment in this group of patients. Objective The objective of this theoretical clinical reasoning model is to provide a framework to help clinicians integrate linear and non-linear clinical reasoning approaches to minimize clinical reasoning errors related to logically fallacious thinking and cognitive biases. Methods This masterclass proposes a hypothesis-driven and probabilistic approach that uses clinical reasoning for managing LBP that seeks to eliminate the challenges related to using any single diagnostic paradigm. Conclusions This model integrates the why (mechanism of primary symptoms), where (location of the primary driver of symptoms), and how (impact of mechanical input and how it may or may not modulate the patient's primary complaint). The integration of these components individually, in serial, or simultaneously may help to develop clinical reasoning through reflection on and in action. A better understanding of what these concepts are and how they are related through the proposed model may help to improve the clinical conversation, academic application of clinical reasoning, and clinical outcomes.
... The use of questionnaires is feasible as they involve self-administered questions and/or simple clinical tests. Three multicomponent systems designed to discriminate between pain mechanisms (Smart,194,(196)(197)(198)175,178 and Kolski 102 classifications) and 3 sets of criteria (Berlin criteria for inflammatory pain, 99,169 RAPIDH criteria for radicular pain [a type of peripheral neuropathic pain], 73 and NeuPSIG neuropathic pain grading system 64,213,220 ) have been tested for validity regarding discrimination between PMCs. Classification systems performed well in most criteria. ...
... Some systems have been developed to discriminate between the 3 main PMCs, their subtypes, or just identify a single PMC. Systems developed by Smart et al. [196][197][198][199] and Nijs et al. 141,144 aim to discriminate between nociceptive, neuropathic, and nociplastic (central sensitisation) pain, whereas the system devised by Schafer et al. 178 aims to discriminate between 3 subgroups of neuropathic pain (denervation, peripheral nerve sensitisation, and neuropathic sensitisation) and nociceptive pain (referred to as musculoskeletal pain). The NeuPSIG neuropathic grading system has been used to identify neuropathic pain. ...
... There is some divergence of opinion regarding the number of categories, terminology, and/or definitions for PMCs and the criteria to discriminate between PMCs ( Table 9). For instance, Smart et al. [196][197][198] described discrimination between 3 PMCs (nociceptive, peripheral neuropathic, central sensitisation pain) and based criteria and validation on a clinical opinion of musculoskeletal physiotherapists. Nijs et al. 141,144 refer to "neuropathic pain" identified by the NeuSPIG criteria (eg, evidence of neural damage) and focus on subjective pain examination and history as evidence of a reasonable explanation for nociceptive pain. ...
Article
Mechanism-based classification of pain has been advocated widely to aid tailoring of interventions for individuals experiencing persistent musculoskeletal pain. Three pain mechanism categories are defined by the International Association for the Study of Pain: nociceptive, neuropathic, and nociplastic pain. Discrimination between them remains challenging. This study aimed to: build on a framework developed to converge the diverse literature of pain mechanism categories to systematically review methods purported to discriminate between them; synthesise and thematically analyse these methods to identify convergence and divergence of opinion; and report validation, psychometric properties and strengths/weaknesses of these methods. The search strategy identified papers discussing methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system. Studies that assessed validity of methods to discriminate between categories were assessed for quality. Extraction and thematic analysis were undertaken on 184 papers. Data synthesis identified 200 methods in five themes: clinical examination, quantitative sensory testing, imaging, diagnostic and laboratory testing, and pain-type questionnaires. Few methods have been validated for discrimination between pain mechanism categories. There was general convergence but some disagreement regarding findings that discriminate between pain mechanism categories. A combination of features and methods, rather than a single method, was generally recommended to discriminate between pain mechanism categories. Two major limitations were identified: overlap of findings of methods between categories due to mixed presentations, and many methods considered discrimination between two pain mechanism categories but not others. The results of this review provide a foundation to refine methods to differentiate mechanisms for musculoskeletal pain.
... In many occasions, differentiating the various phenotypes clinically is difficult. Smart et al [11][12][13] proposed a mechanism-based classification to differentiate between different types of musculoskeletal LBP (central sensitisation, peripheral neuropathic and nociceptive). ...
... The percentage reduction in NRS pain at week 24 will also be evaluated according to various musculoskeletal CLBP subtypes based on pain mechanism (nociceptive vs peripheral neuropathic vs central sanitisation). [11][12][13] The secondary objectives are to evaluate the effects of PLFMF on (1) pain intensity during treatment and early after treatment completion, (2) level of disability, (3) functional levels, (4) sleep quality, (5) quality of life and (6) fatigue in patients with CLBP. The study will also investigate the long-term side effects of PLFMF. ...
... The 38-item clinical criteria checklist developed by Smart et al [11][12][13] will be used to classify patients into different phenotypes of musculoskeletal CLBP. This method of discriminative validity was established. ...
Article
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Introduction The aim of the present study is to investigate the effectiveness of pulsed low-frequency magnetic field (PLFMF) on the management of chronic low back pain (CLBP). Methods and analysis A randomised double-blinded controlled clinical trial will be conducted, involving 200 patients with CLBP. Participants will be randomised in a 1:1 ratio to receive either active PLFMF (experimental arm) or sham treatment (control arm) using a permuted-block design which will be stratified according to three subtypes of musculoskeletal CLBP (nociceptive, peripheral neuropathic or central sanitisation). The intervention consists of three sessions/week for 6 weeks. The primary outcome is the percentage change in Numerical Rating Scale (NRS) pain at week 24 after treatment completion with respect to the baseline. Secondary outcomes include percentage NRS pain during treatment and early after treatment completion, short form 36 quality of life, Roland and Morris Disability Questionnaire; Depression Anxiety Stress Scale 21, Patient Specific Functional Scale, Global perceived effect of condition change, Pittsburgh Sleep Quality Index and Modified Fatigue Impact Scale. Measures will be taken at baseline, 3 and 6 weeks during the intervention and 6, 12 and 24 weeks after completing the intervention. Adverse events between arms will be evaluated. Data will be analysed on an intention-to-treat basis. Ethics and dissemination The study is funded by Imam Abdulrahman Bin Faisal University (IAU). It has been approved by the institutional review board of IAU (IRB‐ 2017‐03–129). The study will be conducted at King Fahd Hospital of the University and will be monitored by the Hospital monitoring office for research and research ethics. The trial is scheduled to begin in September 2018. Results obtained will be presented in international conferences and will be published in peer-reviewed journals. Trial registration number ACTRN12618000921280, prospectively.
... As presented in the PRISMA 2020 flow diagram (Figure 1), from 219 records id fied by the initial literature searches, two hundred and ten were excluded and nine ar were included ( Table 1). The quality of the studies was assessed in Table 2. [38] identified that nociceptive pain is characterized by specific clinical features, including localized pain that is proportional to mechanical triggers, such as movement, posture, or specific activities. These triggers reliably reproduce or alleviate symptoms, making nociceptive pain more predictable compared to other mechanisms. ...
... The studies by Smart et al. (2012c) [38] and Smart et al. (2011) [35] consistently highlighted that nociceptive pain is characterized by symptoms localized to the anatomical site of tissue injury or mechanical dysfunction. These symptoms are proportional to specific aggravating and alleviating factors, such as movement, posture, or mechanical stressors, and respond predictably during clinical assessments. ...
Article
Full-text available
Background: Low back pain (LBP) is a leading cause of disability worldwide, often driven by distinct pain mechanisms: nociceptive, neuropathic, and central sensitization. Accurate classification of these mechanisms is critical for guiding effective, targeted treatments. Methods: A scoping review was conducted following the Joanna Briggs Institute methodology and reported according to PRISMA-ScR guidelines. A comprehensive literature search was performed in MEDLINE, Cochrane CENTRAL, Scopus, PEDro, and Web of Science. Eligible studies included adults with LBP and focused on clinical criteria for classifying pain mechanisms. Data on study methods, population characteristics, and outcomes were extracted and synthesized. Results: Nine studies met the inclusion criteria. Nociceptive pain was characterized by localized symptoms proportional to mechanical triggers, with no neurological signs. Neuropathic pain was associated with burning sensations, dysaesthesia, and a positive neurodynamic straight leg raise (SLR) test. Central sensitization featured widespread pain, hyperalgesia, and disproportionate symptoms. Tools such as painDETECT, DN4, and the Central Sensitisation Inventory (CSI) were validated for neuropathic and central sensitization pain. Central sensitization and neuropathic pain were linked to greater disability and psychological distress compared to nociceptive pain. Conclusions: This review aims to provide a historical perspective on pain mechanism classifications and to explore how previous frameworks have influenced current diagnostic concepts in physiotherapy practice. By synthesizing key clinical criteria used to differentiate between nociceptive, neuropathic, and central sensitization pain, this review proposes a practical framework to improve the accuracy of pain classification in clinical settings.
... Uncertainty about the cause and prolonged symptoms hindered functioning and work, prompting information-seeking behaviors to validate symptoms and facilitate coping. The lack of credible information and healthcare provider explanations fueled fears of serious pathology, exacerbating anxiety and depression [68,69]. ...
... While diagnostic imaging can confirm pathology, it may also exacerbate fear and avoidance behaviors, leading to chronicity [68]. Addressing patients' concerns and providing reassurance and education about pain mechanisms can mitigate maladaptive behaviors and improve outcomes [70,71]. ...
Research
Full-text available
This study investigates how patients' perceptions of lumbar radiculopathy affect their coping strategies and, consequently, their management of the condition. Using a qualitative approach, the researchers analyzed data from 16 studies to identify key findings. They found that patients who view their condition as highly threatening tend to employ maladaptive coping behaviors, while those who perceive it as less threatening are more likely to engage in problem-solving techniques. Interventions aimed at reducing perceived threat levels and enhancing self-efficacy could improve self-management and health outcomes for these patients.
... [11][12][13] A novel idea for effective pain control is focused on identifying one of the three possible pain mechanisms: nociceptive, neuropathic, or nociplastic. 1,[14][15][16] Thus, the treatment would follow the pain type. The problem of determining the dominant pain component, however, has not yet been solved. ...
... The problem of determining the dominant pain component, however, has not yet been solved. 1,14,15 To identify patients who present with symptoms related to central sensitization (nociplastic pain), the patient-reported history, questionnaires, and quantitative sensory testing (QST) are recommended. Unfortunately, there is a lack of directly measurable parameters allowing the confirmation of nociplastic pain. ...
Article
Full-text available
Background The newly proposed low back pain treatment requires case classification according to the pain mechanism (nociceptive, neuropathic or nociplastic) to determine the most effective therapeutic approach. However, there is a lack of objective tools for distinguishing these pain mechanisms. The aim of the study was to identify which symptoms, signs, and standard diagnostic parameters would allow predicting the nociplastic pain (NP) subtype among low back leg pain (LBLP) patients. Methods A retrospective analysis of an LBLP case–control study database was carried out. The presence of NP was assumed if the patient presented with myofascial pain syndrome (MPS) and developed a short-term intensive vasodilatation reaction in the perceived lower leg pain area after provocation by a minimally invasive procedure. Clinical data and standard LBLP diagnostic parameters were analyzed to classify patients as NP (+) vs NP (-). Next, to predict NP probability, logistic regression analysis and a diagnostic classification tree were constructed. Results NP was confirmed in 43.75% of LBLP patients. Women represented 95.24% of all NP (+) patients. The diagnostic classification tree indicated that NP was highly probable if the LBLP subject was female and the result of a positive straight leg raise (SLR) test was lower than 45 degrees. If the SLR test result was greater than or equal to 45 degrees, a negative result on the Bragard test would have diagnostic value. This classification tree was approved to a certain extent in the logistic regression model (deviance residuals, min: −1.8519; 1Q: −0.5551; median: −0.1907; 3Q: 0.6565 and max: 2.1058) but should be verified in a larger group of subjects. Conclusion Female sex, but not clinical data or standard diagnostic parameters, is indicative of nociplastic pain in LBLP patients. More sophisticated statistical methods, based on directly measurable parameters, should be proposed to distinguish NP involvement in LBLP.
... 14 Nociceptive pain is caused by neural signaling in response to chemical (inflammatory), mechanical (tension or compression), and thermal stress. 57 In the low back, nociceptors are located within the major joints, ligaments, and myofascial tissues. 58,59 Conditions consistent with nociceptive signaling (Fig 1) include the following: (1) discogenic pain: pain from nociceptive signaling within the intervertebral disc 60 ; (2) myofascial pain: pain from nociceptive signaling within muscle, tendon, and/or fascial tissues of the low back region; (3) SI joint pain: pain from nociceptive signaling within and surrounding a SI joint 60 ; and (4) zygapophyseal (facet) joint pain: pain from nociceptive signaling within and surrounding a zygapophyseal (facet) joint. ...
... We recommend myofascial pain be defined as nociceptive signaling from within muscle or fascial tissues that may or may not include referred pain or the presence of trigger points (Table 3). 14,15,22,31,32,35,36,41,47,51,57,60,69,70 This broader definition may reduce confusion caused by current descriptions, which instead of defining myofascial pain define myofascial pain syndrome. Diagnostic criteria consistent with this definition and with those recommended by Petersen et al include tenderness within a muscle with or without referred pain and reproduction of familiar pain with palpation or use. ...
Article
Objective: The purpose of this systematic review is to evaluate and summarize current evidence for diagnosis of common conditions causing low back pain and to propose standardized terminology use. Methods: A systematic review of the scientific literature was conducted from inception through December 2018. Electronic databases searched included PubMed, MEDLINE, CINAHL, Cochrane, and Index to Chiropractic Literature. Methodological quality was assessed with the Scottish Intercollegiate Guidelines Network checklists. Results: Of the 3995 articles screened, 36 (8 systematic reviews and 28 individual studies) met final eligibility criteria. Diagnostic criteria for identifying likely discogenic, sacroiliac joint, and zygapophyseal (facet) joint pain are supported by clinical studies using injection-confirmed tissue provocation or anesthetic procedures. Diagnostic criteria for myofascial pain, sensitization (central and peripheral), and radicular pain are supported by expert consensus-level evidence. Criteria for radiculopathy and neurogenic claudication are supported by studies using combined expert-level consensus and imaging findings. Conclusion: The absence of high-quality, objective, gold-standard diagnostic methods limits the accuracy of current evidence-based criteria and results in few high-quality studies with a low risk of bias in patient selection and reference standard diagnosis. These limitations suggest practitioners should use evidence-based criteria to inform working diagnoses rather than definitive diagnoses for low back pain. To avoid the unnecessary complexity and confusion created by multiple overlapping and nonspecific terms, adopting International Association for the Study of Pain terminology and definitions is recommended.
... Manual therapy is a common physiotherapy treatment for LBD (10, 11) but evidence of 18 effectiveness remains limited (12). However, clinical trials often use a generic approach to 19 manual therapy rather than individualising treatment based on pathoanatomical (eg 20 nociceptive source of symptoms), psychosocial (eg fear avoidance), and neurophysiological 21 (eg central sensitisation) barriers to recovery (13)(14)(15)(16)). An individualised approach to manual 22 therapy is more reflective of clinical practice and has been described as being more likely to 23 demonstrate effectiveness in randomised controlled trials (RCTs) (13-16). ...
... In addition no clinical trial has investigated the effectiveness of manual therapy 3 on patients with a "regular compression" pattern of localised unilateral pain reproduced on 4 lumbar extension and ipsilateral lateral flexion (20). This commonly observed (21) 5 presentation has been reported as responding in a consistent and predictable manner to 6 manual therapy techniques (18,22,23) and may comprise features indicative of lumbar 7 zygapophyseal joint pain (24). The aim of this trial was therefore to report the findings of a preplanned subgroup analysis to for which has previously been published (25). ...
Article
Full-text available
Objectives: To determine whether individualised manual therapy plus guideline-based advice results in superior outcomes to advice alone in participants with clinical features potentially indicative of lumbar zygapophyseal joint pain. Design: Multi centre parallel group randomised controlled trial. Setting: 14 physiotherapy clinics in Melbourne, Australia. Participants: Sixty-four participants with clinical features potentially indicative of lumbar zygapophyseal joint pain. Interventions: 10-weeks of physiotherapy comprising individualised manual therapy based on pathoanatomical, psychosocial and neurophysiological barriers to recovery plus guideline-based advice (10 sessions) or advice alone (two sessions). Main outcome measures: Primary outcomes were activity limitation (Oswestry Disability Index), and separate 0 to 10 numerical rating scales for leg pain and back pain. Measures were taken at baseline and 5, 10, 26 and 52-week. Results: Between-group differences for back pain favoured individualised manual therapy over advice for back pain at 5 (1.0; 95% CI 0.6 to 2.0), 10 (1.5; 95% CI 0.5 to 2.4) and 26-weeks (1.4; 95% CI 0.4 to 2.3) as well as for activity limitation at 26 (8.3; 95% CI 2.6 to 14.2) and 52-weeks (8.2; 95% CI 2.3 to 14.2). There were no significant between-group differences for leg pain. Secondary outcomes and responder analyses also favoured individualised manual therapy at almost all time-points. Conclusions: In participants with clinical features potentially indicative of lumbar zygapophyseal joint pain, individualised manual therapy led to greater reduction in back pain at 5, 10 and 26-week follow-up as well as activity limitation at 26 and 52-weeks. Between-group differences were likely to be clinically important. Trial registration: ACTRN12609000334202.
... 20 The initial injury triggers an inflammatory response, causing inflammatory cells (i.e., neutrophils and macrophages) to migrate to the site of injury, releasing cytokines and other pro-inflammatory mediators (i.e., prostaglandins, bradykinin, and substance P) that sensitise the nociceptors, causing pain and damaging muscle fibres and blood vessels. 21 As a result, bleeding and accumulation of interstitial fluid leads to swelling and the formation of a haematoma, so the increased pressure within the muscle can further irritate the nociceptors, which can further contribute to the pain. 22 Isolated rectus femoris muscle tears are rarely reported in the literature. ...
Article
Full-text available
Acute muscle pain is muscle soreness that occurs during or within 24 hours of strenuous activity. Possible causes of acute muscle pain include localized muscle trauma, muscle tear, contusion with acute hemorrhage, or acute compartment syndrome. Isolated ruptures of the rectus femoris muscle are rare clinical conditions that result from excessive muscle strain following an abrupt contraction, incorrect movement, or sudden snap that exceeds the physiological limit of strain that the muscle can withstand. To date, there are few published reports evaluating the results of non-invasive treatment of such injuries. Herein, we report an unusual case of isolated distal rectus femoris tear in a 46-year-old female patient with no risk factors, who initially presented with extensor muscle weakness and pain and was treated conservatively with functional rest, physiotherapy, and cryotherapy.
... 15,16 In a nociceptive driven pain experience, the pain experienced is typically proportionate to the input stimulus, presents with very definite aggravating and easing factors, is often described as a dull ache or a throb at rest, and does not include neurological symptoms associated with sensory changes (numbness, tingling, loss of sensation, etc.). 17 Although the aforemen-tioned process is the most common, some key exceptions should be mentioned. First, injury and pain are not synonymous -people can experience an injury and no pain, and conversely, many people experience pain with no tissue injury. ...
Article
Full-text available
In musculoskeletal and sports medicine, pain has traditionally been linked to tissue injury, often assuming a linear correlation between tissue damage and pain intensity. However, modern pain science has illuminated the complexity of the human pain experience, incorporating psychosocial elements, nervous system sensitization, immune responses, and structural changes in the brain as factors. This contemporary understanding of pain has proven highly beneficial for both clinicians treating individuals in pain and those experiencing pain. Pain neuroscience education (PNE) provides individuals in pain with an understanding of the underlying neurobiology and neurophysiology of their pain experience, which has been shown to result in decreased self-reported pain, reduced disability, the alleviation of fear and fear-avoidance behaviors, diminished pain catastrophizing, and improved movement. Currently, research on PNE predominantly focuses on interventions with individuals with persistent or chronic pain conditions. However, those who experience acute, sub-acute, and perioperative pain also have the potential for elevated levels of fear, fear-avoidance, and pain catastrophizing, indicating potential benefits from PNE. This invited commentary seeks to inform readers about the latest advancements in pain science and propose a conceptual model for delivering PNE in acute pain experiences. Level of Evidence 5
... Specific exercises targeting the back muscles are probably more effective for patients with CLBP of predominantly nociceptive origin [122]. These patients have more localised pain with relatively clear patterns of provocation and reduction with specific postures and movements [134,135]. The premise is that suboptimal loading of spinal structures can be a cause of ongoing nociceptive input in many of these patients and a mechanism for the persistence of their CLBP. ...
Article
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Changes in back muscle function and structure are highly prevalent in patients with chronic low back pain (CLBP). Since large heterogeneity in clinical presentation and back muscle dysfunctions exists within this population, the potential role of back muscle dysfunctions in the persistence of low back pain differs between individuals. Consequently, interventions should be tailored to the individual patient and be based on a thorough clinical examination taking into account the multidimensional nature of CLBP. Considering the complexity of this process, we will provide a state-of-the-art update on back muscle dysfunctions in patients with CLBP and their implications for treatment. To this end, we will first give an overview of (1) dysfunctions in back muscle structure and function, (2) the potential of exercise therapy to address these dysfunctions, and (3) the relationship between changes in back muscle dysfunctions and clinical parameters. In a second part, we will describe a framework for an individualised approach for back muscle training in patients with CLBP.
... When we embrace a complexity mindset to chronic pain resulting from complex, dynamic, and individually unique interactions between the various factors within the more extensive system [20], it allows for a way toward better health and recovery from chronic pain, i.e., when we can utilize a variety of treatments that have various interactions within an individual and their biology and overall pain experience. Although, clinically, therapists have to appreciate that there is heterogeneity in each individual's pain problem, there are also overlapping items that can help us classify pain mechanisms [109][110][111][112][113][114] and lead the clinician toward various treatment options that are the most plausible for improved outcomes (Figure 2). ...
Article
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Pain is an individualized experience for the person suffering from chronic pain. Significant strides have been made in the last few decades in understanding various biological changes that coincide with chronic pain. This state-of-the-art overview looks at the current evidence related to the biology of chronic pain and the implications these findings have on the delivery of pain neuroscience education (PNE). The paper summarizes the various (epi)genetic, neural, endocrine, and immune factors discovered and explored in the scientific literature concerning chronic pain. Each of these biological factors has various implications for the content and delivery of PNE. We discuss the future directions these biological factors have for the clinical implementation of PNE by linking the importance of behavior change, optimizing the learning environment, and using an individualized multimodal treatment approach with PNE. In addition, future directions for research of PNE based on these biological factors are provided with importance placed on individualized patient-centered care and how PNE can be used with traditional modes of care and growing trends with other care methods. PNE was originally and continues to be rooted in understanding chronic pain biology and how that understanding can improve patient care and outcomes.
... La cronificación del dolor implica múltiples procesos relacionados con el sistema nervioso central y periférico que deben de ser distinguidos, especialmente en el deporte, de patrones de sobreuso mecánico recurrentes (Igolnikov et al., 2018). Diferentes autores han propuesto clasificar a los pacientes con dolor musculoesquelético en función del mecanismo de dolor que domina la presentación clínica, con el fin de ofrecer tratamientos más específicos (Chimenti et al., 2018;Smart et al., 2010Smart et al., , 2012. ...
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La conocida complejidad y diversidad de factores asociados a los cuadros de dolor musculoesquelético por sobreuso, la elevada prevalencia de estos cuadros y la escasa investigación disponible en relación con el modelo multidimensional del dolor en el ámbito de la medicina del deporte, hacen necesaria una actualización de los marcos conceptuales clásicos de investigación, razonamiento y tratamiento del deportista con dolor.
... ese results indicated that specific pain quality inhibited muscle activity near the pain site during the trunk extension. "Intermittent pain" indicates the periodic activation of primary nociceptors in response to mechanical stimuli, as mediated by Aδ-fiber transmission [19]. In other words, "intermittent pain" may reflect the pain quality derived from nociceptive pain. ...
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Background: Pain can alter muscle activity, although it is not clear how pain intensity and site location affect muscle activity. This study aimed to reveal the complex associations among the pain site, pain intensity/quality, muscle activity, and muscle activity distribution. Methods: Electromyographic signals were recorded from above a bilateral lumbar erector spinae muscle with a four-channel electrode in 23 patients with chronic low back pain while they performed a lumbar bending and returning task. We calculated the average value of muscle activity during the extension phase (agonist activity) and the centroid of muscle activity, as well as the distance between the centroid of muscle activity and pain site. We also assessed the pain site and pain intensity/quality by the interview and questionnaire method. A generalized linear mixed model analysis was performed to determine the relationships among pain intensity/quality, pain site, and muscle activity. Results: The results showed that muscle activity during the extension phase was significantly negatively associated with neuropathic pain and "pain caused by light touch." In addition, the distance between the centroid of muscle activity and pain site during the extension phase was significantly positively associated with intermittent pain, "throbbing pain," "splitting pain," "punishing-cruel," and "pain caused by light touch." Conclusions: Our findings suggest the existence of a motor adaptation that suppresses muscle activity near the painful area as the pain intensity increases. Furthermore, the present study indicates that the presence or absence of this motor adaptation depended on the pain quality.
... 28,29 For example LBP that is localized, mechanically provoked and linked to maladaptive functional and lifestyle behaviours, resulting in abnormal tissue loading, may be associated with nociceptive and infl ammatory pain features such as localized heat and pressure hyperalgesia. 30,31 In contrast, 'insidious' pain fl ares or PLBP linked to other pain and health co-morbidities and high levels of psychosocial and lifestyle stresses, is often widespread and non-mechanical in nature. This may present with either an absence of clinical signs or be associated with exaggerated pain responses to minor mechanical triggers with localized allodynia and/or widespread cold hyperalgesia. ...
... Patients presenting to therapy with nociceptive pain present with a cluster of clinical criteria predictive of nociceptive pain, including pain localized to the area of pain or dysfunction; clear, proportionate mechanical or anatomical nature to aggravating and easing factors; usually intermittent and sharp with movement or mechanical provocation; may be a more constant dull ache or throb at rest; the absence of pain in association with other dysesthesias; night pain with disturbed sleep; antalgic postures or movement patterns; and pain variously described as burning, shooting, sharp, or electric shock-like. 61 In most outpatient hand therapy settings, this will likely represent a large portion of the patients treated. Therapeutic exercise interventions for patients with nociceptive pain are in large part based on the physical impairments noted on the evaluation. ...
... 288,293,296 Patients with nociceptive pain are recognized by having localized proportionate pain with aggravating and alleviating factors, and the absence of night pain and other factors. 297 For example, an acute discogenic radicular sciatic pain patient with antalgia would classify as nociceptive. The TNE approach should also be used in these patients but less emphasis is placed on it. ...
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• The treatment of sciatica differs according to its cause • Most cases warrant a trial of conservative treatment • Integrated programs including manual therapies and exercise may be superior to any single therapy • Surgery is indicated in the presence of red flags and/or a lack of response to conservative treatment
... Although genetic factors, adverse childhood experiences, and mood and anxiety disorders are risk factors that have been associated with nociplastic pain, it is still unknown why some individuals develop this condition (Kosek et al., 2016). Individuals who predominantly exhibit nociplastic pain-related mechanisms are likely to present with chronic musculoskeletal complaints, such as CLBP (Arendt-Nielsen et al., 2018;Dunn, 2001;Meeus et al., 2008;Moseley and Flor, 2012;Nijs et al., 2014;Smart et al., 2012;Walitt, Ceko, Gracely, and Gracely, 2016). ...
Article
Background: Sensory profiles (SPs) may be useful in classifying patients based on sensory sensitivity and behavioral responses to stimuli to develop personalized treatments for nonspecific chronic low back pain (CLBP). The Adolescent/Adult Sensory Profile (AASP) identifies four sensitivity and behavioral response-related quadrants: Sensory Sensitive, Sensation Avoiding, Low Registration, and Sensation Seeking. It is an appropriate questionnaire for evaluating SPs; however, it has not been validated in CLBP. Objectives: To assess the internal consistency, test-retest reliability, agreement, and construct validity of the AASP in a CLBP population with nociplastic pain in primary care physiotherapy. Design: Two evaluations were performed at a 2-week interval in this non-experimental cross-sectional study. Participants: Patients with CLBP. Methods: Questionnaires were used to compare outcomes with the AASP. Reliability was evaluated by assessing internal consistency and test-retest reliability. Construct validity was evaluated in response to the a priori hypothesis. Results: Ninety patients with CLBP were included. Internal consistency was excellent for all SPs (Cronbach's alpha, 0.91-0.92). Test-retest reliability Intraclass Correlation Coefficient (ICC (3,2)) 0.82-0.87, for the SPs (95% CI 0.74-0.91, p< .001). Construct validity correlated positively with Low Registration, Sensory Sensitive, and Sensation Avoiding and negatively with Sensation Seeking. Conclusion: The AASP is suitable for evaluating SPs in primary care CLBP patients.
... [15][16][17] It has been broadly discussed that identification of mechanism and subsequent classification of patients to a pain mechanism category (PMC) may be based on the characteristics of their presentation. [18][19][20][21] On this basis, many different groupings have been proposed with a diversity of terminology and proposed features. 11,15,18 The expansive research on this issue has resulted in considerable confusion. ...
Article
Objectives: Improvements in pain management might be achieved by matching treatment to underlying mechanisms for pain persistence. Many authors argue for a mechanism-based classification of pain, but the field is challenged by wide variation in proposed terminology, definitions and typical characteristics. This study aimed to: (i) systematically review mechanism-based classifications of pain experienced in the musculoskeletal system; (ii) synthesise and thematically analyse classifications, using the International Association for the Study of Pain categories of nociceptive, neuropathic and nociplastic as an initial foundation; and (iii) identify convergence and divergence between categories, terminology, and descriptions of each mechanism-based pain classification. Methods: Databases were searched for papers that discussed a mechanism-based classification of pain experienced in the musculoskeletal system. Terminology, definitions, underlying neurobiology/pathophysiology, aggravating/easing factors/response to treatment, and pain characteristics were extracted and synthesised based on thematic analysis. Results: From 224 papers, 174 terms referred to pain mechanisms categories. Data synthesis agreed with broad classification based on ongoing nociceptive input, neuropathic mechanisms, and nociplastic mechanisms (e.g. central sensitisation). “Mixed”, “other”, and the disputed categories of “sympathetic” and “psychogenic” pain, were also identified. Thematic analysis revealed convergence and divergence of opinion regarding definitions, underlying neurobiology and characteristics. Discussion: Some pain categories were defined consistently, and despite the extensive efforts to develop global consensus on pain definitions, disagreement still exists regarding how each could be defined, subdivided and their characteristic features that could aid differentiation. These data form a foundation for reaching consensus on classification.
... 33 Included in Tables 2 and 3 are characteristics for neuropathic and nociceptive pain based on current expert consensus opinion. 12,37 Based largely on these consensus-based criteria and International Association for the Study of Pain definitions, 21 several validated questionnaire instruments have been designed for in-office use to screen for neuropathic pain. These include the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), S-LANSS (self-report version of LANSS), painDETECT questionnaire, McGill Pain Questionnaire, Standardized Evaluation of Pain tool, Douleur Neruopathique 4 (DN4), ID Pain questionnaire, and Patient-Reported Outcome Measurement Information System Neuropathic Pain Quality Scale. ...
Article
Objective: The purpose of this study was to use scientific evidence to develop a practical diagnostic checklist and corresponding clinical exam for patients presenting with low back pain (LBP). Methods: An iterative process was conducted to develop a diagnostic checklist and clinical exam for LBP using evidence-based diagnostic criteria. The checklist and exam were informed by a systematic review focused on summarizing current research evidence for office-based clinical evaluation of common conditions causing LBP. Results: Diagnostic categories contained within the checklist and exam include nociceptive pain, neuropathic pain, and sensitization. Nociceptive pain subcategories include discogenic, myofascial, sacroiliac, and zygapophyseal (facet) joint pain. Neuropathic pain categories include neurogenic claudication, radicular pain, radiculopathy, and peripheral entrapment (piriformis and thoracolumbar syndrome). Sensitization contains 2 subtypes, central and peripheral sensitization. The diagnostic checklist contains individual diagnostic categories containing evidence-based criteria, applicable examination procedures, and checkboxes to record clinical findings. The checklist organizes and displays evidence for or against a working diagnosis. The checklist may help to ensure needed information is obtained from a patient interview and exam in a variety of primary spine care settings (eg, medical, chiropractic). Conclusion: The available evidence informs reasonable working diagnoses for many conditions causing or contributing to LBP. A practical diagnostic process including an exam and checklist is offered to guide clinical evaluation and demonstrate evidence for working diagnoses in clinical settings.
... 'pain localized to the area of injury/dysfunction', 'clear, proportionate mechanical/anatomical nature to aggravating and easing factors', 'pain is usually intermittent and sharp with movement/mechanical provocation', etc.). 41 On the other hand, a predominant central/nociplastic pain mechanism is usually characterized by the lack of a consistent clinical pattern (e.g. 'disproportionate, non-mechanical, unpredictable pattern of pain provocation in response to multiple/nonspecific aggravating/easing factors'). ...
Article
Objective: To examine the interrater reliability and agreement of a pain mechanisms-based classification for patients with nonspecific neck pain (NSNP). Methods: Design - Observational, cross-sectional reliability study with a simultaneous examiner design. Setting: University hospital-based outpatient physical therapy clinic. Participants: A random sample of 48 patients, aged between 18 and 75 years old, with a primary complaint of neck pain was included. Interventions: Subjects underwent a standardized subjective and clinical examination, performed by 1 experienced physical therapist. Two assessors independently classified the participants' NSNP on 3 main outcome measures. Main outcome measures: The Cohen kappa, percent agreement, and 95% confidence intervals (CIs) were calculated to determine the interrater reliability for (1) the predominant pain mechanism; (2) the predominant pain pattern; and (3) the predominant dysfunction pattern (DP). Results: There was almost perfect agreement between the 2 physical therapists' judgements on the predominant pain mechanism, kappa=.84 (95% CI, .65-1.00), p<.001. There was substantial agreement between the raters' judgements on the predominant pain pattern and predominant DP with respectively kappa=.61 (95% CI, .42-.80); and kappa=.62 (95% CI, .44-.79), p<.001. Conclusion(s): The proposed classification exhibits substantial to almost perfect interrater reliability. Further validity testing in larger neck pain populations is required before the information is used in clinical settings. Clinical trial registration number: NCT03147508 (https://clinicaltrials.gov/ct2/show/NCT03147508).
... An initial draft of the survey was developed following a review of literature on exercise for LBP (Geneen Louise et al., 2017;Jesus-Moraleida Fabianna et al., 2016;Searle et al., 2015) and previous LBP surveys (Byrne et al., 2006;Liddle et al., 2009;Daulat, 2013;Keating et al., 2016). Following this, vignettes were developed based on common presentations of LBP derived from clinical and pain mechanism-based classification guidelines (Airaksinen et al., 2006;Van Tulder et al., 2006;Smart et al., 2012aSmart et al., , 2012bNijs et al., 2015). Vignettes have been used previously to assess primary care management of LBP (Keating et al., 2016;Bishop et al., 2016;Ryan et al., 2013), and are a valid measure of clinical behaviour (Peabody et al., 2000(Peabody et al., , 2004. ...
Article
Objectives: To explore the type of exercise prescribed by Australian health professionals for LBP, and whether the exercises prescribed are pain-free or into pain. Methods: A survey of physiotherapists and exercise physiologists was conducted from all states/territories in Australia. The survey contained two chronic LBP vignettes with different pain mechanisms (dominant nociceptive or central sensitisation pain) and one acute LBP vignette. Respondents were asked if they would prescribe advice to stay active and exercise. If exercise was prescribed, respondents were asked to specify the type and pain provoking nature (exercise with no pain, exercise to the start of pain, exercise with pain at a tolerable level or exercise irrespective of pain). Results: The response rate was 17%(218/1276). Most respondents prescribed advice to stay active(≥95%) and exercise(≥90%) for all vignettes. Irrespective of the vignette, several exercises were prescribed [aerobic (57-85% of clinicians), motor control (62-84% of clinicians), range of motion (72-75% of clinicians)]. Strengthening exercise was prescribed more for chronic(>60%) than acute LBP(23%). Irrespective of the exercise, between 20 and 25% of respondents prescribed pain-free exercise, between 71 and 79% of respondents prescribed exercise into pain, and ≤4% prescribed exercise irrespective of pain for acute and chronic LBP. Conclusions: Several exercises are prescribed for LBP, irrespective of pain mechanism or duration, with more clinicians prescribing strengthening exercise for chronic than acute LBP. Most clinicians prescribed exercise into pain for acute and chronic LBP, irrespective of the exercise. Further research should determine which exercises are beneficial based on pain mechanism and duration, and whether exercise into pain should be prescribed for LBP.
... Jaywant and Pai in 2003 stated that the numeric rating scale is more valid than other scales, and thus, in our study, we consider the numeric value of 3. [16] Ear-related pain conditions showed prevalence rate of 6.99% with male predominance at a significant lower mean age group of 11.71 years age for males 14 years age for females compared to total mean age of the study population (38.17 years for males and 50 years for females). Similar kinds of results were obtained from Smart et al. with similar prevalence rate, [17] Bhattacharya (2009) stating male prevalence, [18] and Teixido and Carey (2014) analyzed similar type of quality of pain. [19] Throat and neck disorder pain conditions showed prevalence rate of 6.29% with male predominance at a significantly lower mean age group of 28 years for males and 31.8 years for females compared to total mean age of the study population (38.17 years for males and 50 years for females). ...
Article
Les effets secondaires (ES) des consultations d'ostéopathie sont à la fois fréquents et difficilement prévisibles, et leur étude dans le cadre de l'apprentissage clinique a été très peu abordée. L'objectif de cette étude était de mettre en évidence les caractéristiques et les facteurs de risque de présenter des ES dans un cadre clinique. Une étude rétrospective sur 62 dossiers a été effectuée. Les dossiers devaient contenir des informations concernant la présence ou non d'ES, des informations concernant la qualité de vie du patient, ses antécédents et le traitement ostéopathique effectué. Un modèle de régression logistique multivariée a permis de tester le lien entre la présence d'ES (variable expliquée) et diverses variables concernant le patient et sa prise en charge ostéopathique récoltées dans les dossiers cliniques. La moitié des dossiers rapportaient des ES apparaissant pour 80 % d'entre eux moins de 24 heures après la consultation et disparaissant en moins de trois jours. Plusieurs variables favorisaient l'apparition des ES. Elles étaient en lien avec le patient (cervicalgie, dorsalgie ou signes céphaliques, et une qualité de vie psychique faible, p < 0,05), et d'autres en lien avec la prise en charge (nombre de techniques important et nombreuses techniques haute vélocité et basse amplitude (HVBA), p < 0,01). En améliorant les connaissances sur les ES, cette recherche permettra d'obtenir un consentement plus éclairé du patient. Des recherches permettant de mieux appréhender le lien entre les ES et l'évolution du motif de consultation pourraient améliorer nos connaissances des effets d'une consultation ostéopathique. https://www.larevuedelosteopathie.com/articles/176
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This chapter reviews non pharmacologic and non surgical treatments for spine pain. Evidence based treatments are emphasized and discussed. Non pharmacological treatments are recommended as first line care, reducing the need for more aggressive interventions.KeywordsNon pharmacological treatment Back pain ExerciseEvidence based treatment
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Persistence of low back pain is thought to be associated with different underlying pain mechanisms, including ongoing nociceptive input and central sensitisation. We hypothesised that primary motor cortex (M1) representations of back muscles (a measure of motor system adaptation) would differ between pain mechanisms, with more consistent observations in individuals presumed to have an ongoing contribution of nociceptive input consistently related to movement/posture. We tested 28 participants with low back pain sub‐grouped by the presumed underlying pain mechanisms: nociceptive pain, nociplastic pain, and a mixed group with features consistent with both. Transcranial magnetic stimulation was used to study M1 organization of back muscles. M1 maps of multifidus (deep & superficial), and longissimus erector spinae were recorded with fine‐wire electromyography and thoracic erector spinae with surface electromyography. The nociplastic pain group had greater variability in M1 map location (centre of gravity) than other groups (p<0.01), which may suggest less consistency, and perhaps relevance, of motor cortex adaptation for that group. The mixed group had greater overlap of M1 representations between deep/superficial muscles than nociceptive pain (deep multifidus/longissimus: p=0.001, deep multifidus/thoracic erector spinae: p=0.008), and nociplastic pain (deep multifidus/longissimus: p=0.02, deep multifidus/thoracic erector spinae: p= 0.02) groups. This study provides preliminary evidence of differences in M1 organisation in subgroups of low back pain classified by likely underlying pain mechanisms. Despite the sample size, differences in cortical re‐organisation between subgroups were detected. Differences in M1 organisation in subgroups of low back pain supports tailoring of treatment based on pain mechanism and motor adaptation.
Article
Background Further clinical data how low-back pain (LBP) symptoms and signs manifests in physiotherapy clinical reasoning and treatment decision-making is needed. Objective The aim was to explore and describe how symptoms and signs portrayed in three case descriptions of LBP influences physiotherapy treatment decision-making. Design This was an exploratory interview study using inductive content analysis. Method Fifteen semi-structured individual interviews were used to collect data of physiotherapists’ treatment decision-making regrading three diverse LBP case descriptions. The participants were men, women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden. Findings Two overarching themes were identified influencing decision-making for the treatment of LBP:1) Explicit assessment features distinguish treatment approaches; with categories describing how symptoms and signs were used to target treatment (nature of pain induce reflections on plausible cause; narrative details trigger attention and establishes knowledge-enhancing foci; pain-movement-relationship is essential; diverse emphasis of pain modulation and targeted treatment approaches): and 2) Preconceived notion of treatment, with categories describing personal treatment rationales, unrelated to the presented symptoms and signs (passive treatment avoidance and motor control exercise ambiguity). Conclusion This study identifies how assessment details lead to decisions on diverse treatment approaches for LBP, but also that treatment decisions can be based on preconceived beliefs unrelated to the clinical presentation. The results underpin the mix of knowledge sources that clinicians need to balance and the necessity of self-awareness of preconceptions for informed and meaningful clinical decision-making.
Article
Background: Explaining pain to patients through pain neuroscience education (PNE) is currently a widespread treatment studied in the musculoskeletal context. Presently, there is sufficient evidence supporting the effectiveness of PNE in patients with chronic musculoskeletal disorders. However, clinicians must pay attention to the actual possibility to transfer research findings in their specific clinical context. Objective: We analysed the applicability of results of studies focused on PNE, which has not been done previously. Methods: A detailed discussion on PNE applicability is provided, starting from published randomized controlled trials that investigated the effectiveness of PNE. Results: This paper markedly points out the awareness of clinicians on the need for an accurate contextualization when choosing PNE as an intervention in clinical practice.
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The aim of this chapter is to provide an overview of the most common, evidence-based techniques and approaches used by physical therapists to evaluate and treat patients with pain. The first section on evaluation includes examination techniques, prognosis, and patient diagnosis/classification. The second section on treatment presents management strategies linked to a pain mechanism classification scheme of nociceptive, neuropathic, or nociplastic pain. Specific recommendations from clinical practice guidelines are included for the physical therapy management of spinal pain, lower extremity osteoarthritis, radiculopathy, carpal tunnel syndrome, fibromyalgia, and complex regional pain syndrome, type I.
Article
Background Patellofemoral pain (PFP) is defined biomechanically, but is characterised by features that fit poorly within nociceptive pain. Mechanisms associated with central sensitisation may explain why, for some, symptoms appear nociplastic. This study compares psychological and somatosensory characteristics between those with persistent PFP and controls. Methods 150 adults with PFP were compared to 61 controls. All participants completed a survey evaluating participant characteristics, PFP‐related constructs and psychological factors: anxiety, depression, pain catastrophizing, kinesiophobia, pain self‐efficacy. Participants also attended a session of somatosensory testing, which included knee and elbow thermal and mechanical detection and pain thresholds, conditioned pain modulation (CPM), and temporal summation of pain (TSP). Differences were evaluated using analysis of covariance (sex as covariate). Multivariate backward stepwise linear regression examined how psychological and somatosensory variables relate to PFP (Knee injury & Osteoarthritis Outcome Score‐patellofemoral). Results The PFP group had multimodal reduced pain thresholds at the knee and elbow (Standardised Mean Difference (SMD), p: 0.86 to 1.2, <0.001), reduced mechanical detection at the elbow (0.43, 0.01) and higher TSP (0.41, 0.01). CPM was not different. Psychological features demonstrated small effects (0.47‐0.59, 0.01‐0.04). The PFP group had a 55% (95% CI: 0.47 to 0.62) risk of kinesiophobia and an 11% (0.06 to 0.15) reduced pain self‐efficacy risk. Kinesiophobia, knee pressure pain threshold, pain self‐efficacy and pain catastrophizing explained 40% of KOOS‐PF variance (p = <0.001). Conclusions Widespread hyperalgesia and evidence of symptom amplification may reflect nociplastic pain. Clinicians should be aware that kinesiophobia and the nociplastic pain may characterise the condition. Significance (1) Individuals with patellofemoral pain have widespread reduced pain thresholds to pressure and thermal stimuli. (2) Mechanically‐induced pain is likely amplified in those with patellofemoral pain. (3) Pain‐related fear is highly prevalent and helps explain patellofemoral pain‐related disability. What’s already known about this topic? (1) Pressure pain threshold can be lower in individuals with patellofemoral pain. What does this study add? (1) This is the first study to explore a combined range of psychological and psychophysical tests in patellofemoral pain. (2) This study provides strong evidence of nociplastic pain in patellofemoral pain.
Article
Background: Low back pain (LBP) is a very common pain problem in powerlifters. There is a lack of evidence to guide powerlifters and health-care professionals in understanding the role of powerlifting in the development of LBP and treatment of injuries in powerlifters. This study aimed to describe functional impairments and patho-anatomical findings in eight powerlifters with and without LBP. Methods: First, four powerlifters with LBP were recruited. Each powerlifter was then matched with a pain-free lifter (Control) by age, Body Mass Index and competition weight class. They all performed physical performance tests and were examined with magnetic resonance imaging. Four weeks prior to the examination the powerlifters also recorded training load. Powerlifters with LBP were also examined by a physiotherapist in order to define their pain and impairments. Results: The four male powerlifters with LBP had a nociceptive pain associated with non-ideal squatting technique, higher flexibility in their lumbar spine than in their hips and patho-anatomical findings such as degenerated discs (four), spondylolysis (one) and spinal stenosis (one). However, the controls also showed similar functional impairments and patho- anatomical findings. Conclusions: Powerlifters with and without LBP show similar functional impairments and patho-anatomical findings. However, powerlifters' LBP seems associated with pain during movement and loading of the lumbar spine. The association and causation between specific functional impairments, patho-anatomical findings and LBP in powerlifters has to be further investigated in studies including more participants.
Article
Synopsis: Pain is complex. It is no longer acceptable to consider pain solely as a peripheral phenomenon involving activation of nociceptive neurons. The contemporary understanding of pain involves consideration of different underlying pain mechanisms and an increasing awareness of plasticity in all of the biological systems. Of note, recent advances in technology and understanding have highlighted the critical importance of neuroimmune interactions, both in the peripheral and central nervous systems, and the interaction between the nervous system and body tissues in the development and maintenance of pain, including low back pain (LBP). Further, the biology of many tissues changes when challenged by pain and injury, as reported in a growing body of literature on the biology of muscle, fat, and connective tissue. These advances in understanding of the complexity of LBP have implications for our understanding of pain and its interaction with the motor system, and may change how we consider motor control in the rehabilitation of LBP. This commentary provides a state-of-the-art overview of plasticity of biology in LBP. The paper is divided into 4 parts that address (1) biology of pain mechanisms, (2) neuroimmune interaction in the central nervous system, (3) neuroimmune interaction in the periphery, and (4) brain and peripheral tissue interaction. Each section considers the implications for clinical management of LBP. J Orthop Sports Phys Ther 2019;49(6):389-401. doi:10.2519/jospt.2019.8716.
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L'algologia e l'algologo Negli ultimi decenni si sta affermando una nuova figura nel già "affollato" panorama di sanitari che trattano il dolore: l'algologo (o medico del dolore). Se la definizio-ne del dolore dell'International Association for the Study of Pain (IASP) è ormai un sapere condiviso dai più, una precisa e unanime definizione di medicina del do-lore non è stata ancora data. Molti autorevoli istituti di ricerca d'oltreoceano si sono dotati dunque di proprie definizioni, che già da una sommaria analisi comparata, convergono su vari punti: » porre diagnosi sul tipo di dolore; » interdisciplinarietà; » disporre di terapie specifiche per tipo di dolore; » porsi l'obiettivo di migliorare la qualità di vita. Se si va a guardare il "core curriculum" della IASP (1), su che preparazione deve avere un professionista che si occupa di dolore, ci si rende immediatamente conto che l'algologo non è l'esclusivo detentore delle conoscenze di neurobiologia e clinica del dolore; la cosiddetta "pain science" è una condizione curriculare necessaria al medico, al fisioterapista, infermiere, psicologo e perfi-no all'operatore sociale, che crea quel terreno culturale comune imprescindibile per una multi-e inter-disci-plinarietà. Ma quello che determina la differenza tra tutte le figure, è come viene declinata la "pain science" in saperi e pratiche specifiche. Ne nasce o (o dovrebbe nascerne) una medicina del dolore, una fisioterapia del dolore, una psicologia del dolore, una cura (in senso in-fermieristico) del dolore ecc. In accordo con quanto ap-pena detto, possiamo dunque, pragmaticamente, dire che la medicina del dolore è: ricerca, diagnosi e deci-sione terapeutica, finalizzata alla cura del paziente con dolore, nonché al suo recupero secondo un approccio bio-psico-sociale. L'approccio bio-psico-sociale in medicina del dolore parte proprio dalla definizione IASP di dolore, che essendo multidimensionale ab origine, riesce a ben conciliare "visioni" apparentemente dif-ferenti come: la patologia d'organo, la neurofisiologia del dolore, i fattori psicologici, ambientali e le strategie motorie e comportamentali. Questi vari approcci diversi al fenomeno dolore, giocano tutti, in misura diversa e sempre individualizzata, un ruolo nella percezione del dolore. Nella medicina del dolore si distinguono tre mo-menti fondamentali: 1. un momento diagnostico specifico dove si fa dia-gnosi di tipo e di patogenesi di dolore; 2. una terapia specifica per tipo di dolore; 3. un programma terapeutico (in cui si evidenzieranno le eventuali figure "altre", a cui inviare per la terapia). Classificazione patogenetica del dolore La classificazione patogenetica del dolore nasce in que-sti tre ultimi decenni, all'interno dell'approfondimento clinico della "pain science" e si focalizza sulla com-plessa "processazione" dello stimolo nocicettivo, dalla periferia al centro e sulle modificazioni biochimiche e neuroplastiche che avvengono dal recettore, alla fibra, al ganglio, al midollo, fino alle cortecce sensitive, emo-zionali e valutative. I tre capisaldi della diagnosi patoge-netica sono: 1. la distinzione tra dolore fisiologico e patologico; 2. la ricerca della sede della lesione algogena (il "pain generator") e del meccanismo molecolare che sot-tende la lesione algogena (la patogenesi del dolore); 3. diagnosi dei fenomeni di cronicizzazione. La classificazione patogenetica pone il dolore come protagonista assoluto, liberandolo da rapporti di con
Article
When dealing with chronic pain, it is often not possible for clinicians to provide adequate answers to their patients about what might be wrong, and why they continue to have their pain. This has led to greater use of diagnostic “labels” for conditions such as fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, chronic Lyme disease, and many others. Assigning such “labels” to patients with chronic pain has far-reaching consequences for all stakeholders. The aim of this clinical commentary is to highlight some of the common threads among 4 particular conditions common to women—fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, and chronic Lyme disease—when it comes to the underlying neurobiology and its consequences for the patient and treating clinicians. By taking a “big picture” view of pain as a multiple system output activated in response to threat, we discuss how the various output systems activated can lead to clusters of symptoms that may predispose patients to one or other of these 4 diagnostic conditions. There is now emerging evidence that during the biological response to threat, one output system may be more affected than the others and dominate the clinical picture, hence manifesting as a particular diagnostic condition. We propose that ultimately, these conditions essentially mean the same thing, that the patient has chronic pain, and we advocate for treatment of the patient, not the condition. The ability to look beyond the “label” and seeing the person in front of you is imperative when it comes to providing hope.
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Thesis
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Political science researchers typically conduct an idiosyn- cratic search of possible model configurations and then present a single specification to readers. This approach systematically understates the uncertainty of our results, generates fragile model specifications, and leads to the estimation of bloated models with too many control vari- ables. Bayesian model averaging (BMA) offers a sys- tematic method for analyzing specification uncertainty and checking the robustness of one's results to alterna- tive model specifications, but it has not come into wide usage within the discipline. In this paper, we introduce important recent developments in BMA and show how they enable a different approach to using the technique in applied social science research. We illustrate the method- ology by reanalyzing data from three recent studies us- ing BMA software we have modified to respect statisti- cal conventions within political science.
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Physiotherapy has long been part of the overall intervention for the attempted rehabilitation of patients with pain and disability following peripheral (and central) nerve damage. In musculoskeletal physiotherapy (a subspecialty), a movement-based assessment and treatment protocol has been devised that is guided by, among other things, therapists' perceptions of patients' responses to mechanical stimuli, including various tests of 'neural tension'. Recently, this process together with provocative tests of sensation has been employed to identify, and predict outcomes for, patients suspected of having a 'neural tissue' component to their pain and consequent disability (either fascicular damage or 'neuritis'). However, some of the syndromes involved are controversial, and uncertainty still surrounds the diagnosis, mechanisms and, therefore, effective treatment of the highly complex symptom, true neuropathic pain. In this review, the current basic scientific evidence for the proposed cause, and often intractable nature, of neuropathic pain is presented and discussed with reference to musculoskeletal therapy. It will be seen that peripheral nerve damage has the potential to create potentially irreversible changes in (peripheral and) central nervous system structure and function that have, to date, largely defied effective medical treatment. For musculoskeletal physiotherapy to discriminate accurately and, where appropriate, intervene (or not) responsibly, it would seem constructive to incorporate this (and other) mechanisms-related evidence into its clinical reasoning and decision-making process.
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As a mechanisms-based classification of pain 'central sensitisation pain' (CSP) refers to pain arising from a dominance of neurophysiological dysfunction within the central nervous system. Symptoms and signs associated with an assumed dominance of CSP in patients attending for physiotherapy have not been extensively studied. The purpose of this study was to identify symptoms and signs associated with a clinical classification of CSP in patients with low back (± leg) pain. Using a cross-sectional, between-subjects design; four hundred and sixty-four patients with low back (± leg) pain were assessed using a standardised assessment protocol. Patients' pain was assigned a mechanisms-based classification based on experienced clinical judgement. Clinicians then completed a clinical criteria checklist specifying the presence or absence of various clinical criteria. A binary logistic regression analysis with Bayesian model averaging identified a cluster of three symptoms and one sign predictive of CSP, including: 'Disproportionate, non-mechanical, unpredictable pattern of pain provocation in response to multiple/non-specific aggravating/easing factors', 'Pain disproportionate to the nature and extent of injury or pathology', 'Strong association with maladaptive psychosocial factors (e.g. negative emotions, poor self-efficacy, maladaptive beliefs and pain behaviours)' and 'Diffuse/non-anatomic areas of pain/tenderness on palpation'. This cluster was found to have high levels of classification accuracy (sensitivity 91.8%, 95% confidence interval (CI): 84.5-96.4; specificity 97.7%, 95% CI: 95.6-99.0). Pattern recognition of this empirically-derived cluster of symptoms and signs may help clinicians identify an assumed dominance of CSP in patients with low back pain disorders in a way that might usefully inform their management.
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As a mechanisms-based classification of pain 'peripheral neuropathic pain' (PNP) refers to pain arising from a primary lesion or dysfunction in the peripheral nervous system. Symptoms and signs associated with an assumed dominance of PNP in patients attending for physiotherapy have not been extensively studied. The purpose of this study was to identify symptoms and signs associated with a clinical classification of PNP in patients with low back (± leg) pain. Using a cross-sectional, between-subjects design; four hundred and sixty-four patients with low back (± leg) pain were assessed using a standardised assessment protocol. Patients' pain was assigned a mechanisms-based classification based on experienced clinical judgement. Clinicians then completed a clinical criteria checklist specifying the presence or absence of various clinical criteria. A binary logistic regression analysis with Bayesian model averaging identified a cluster of two symptoms and one sign predictive of PNP, including: 'Pain referred in a dermatomal or cutaneous distribution', 'History of nerve injury, pathology or mechanical compromise' and 'Pain/symptom provocation with mechanical/movement tests (e.g. Active/Passive, Neurodynamic) that move/load/compress neural tissue'. This cluster was found to have high levels of classification accuracy (sensitivity 86.3%, 95% CI: 78.0-92.3; specificity 96.0%, 95% CI: 93.4-97.8; diagnostic odds ratio 150.9, 95% CI: 69.4-328.1). Pattern recognition of this empirically-derived cluster of symptoms and signs may help clinicians identify an assumed dominance of PNP mechanisms in patients with low back pain disorders in a way that might usefully inform subsequent patient management.
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ObjectiveIn light of recent advances in understanding of the neurophysiological basis of pain, the use of mechanisms-based clinical reasoning strategies for pain has been advocated within physiotherapy. The purpose of this qualitative study was to investigate the nature and extent of mechanisms-based clinical reasoning of pain by experienced musculoskeletal physiotherapists, in relation to three different clinical pain presentations.Design/participantsGuided by an interpretative approach, a qualitative multiple-case studies design was used. Three videotaped patient–therapist clinical interviews were produced, each describing a different pain presentation. During and after the viewing of each of the three pain presentations, an audiotaped semi-structured interview was carried out with a purposive sample of seven experienced physiotherapists. The therapists were encouraged to verbalise their thoughts on aspects of each patient's pain presentation. All interviews were subsequently transcribed, coded and analysed.ResultsFour main categories of mechanisms-based clinical reasoning were identified. These were: (1) nociceptive; (2) peripheral neurogenic; (3) central; and (4) autonomic/sympathetic. There was some evidence to suggest that reasoning within these categories variously influenced therapists’ prognostic decision making as well as the planning of physical assessments and treatment. There was minimal evidence of reasoning according to the cognitive–affective mechanisms of pain, and no evidence of reasoning associated with motor, neuroendocrine and immune mechanisms and influences on nociception.ConclusionThe mechanisms-based clinical reasoning of pain by the participants in this study appeared to reflect the integration of a limited understanding of the neurophysiological basis of pain into clinical decision making associated with patients with musculoskeletal disorders. Physiotherapists may benefit from continuing education in order to broaden and update their knowledge of applied pain neurophysiology.
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Neuropathic pain is common in many diseases or injuries of the peripheral or central nervous system, and has a substantial impact on quality of life and mood. Lesions of the nervous system may lead to potentially irreversible changes and imbalance between excitatory and inhibitory systems. Preclinical research provides several promising targets for treatment such as sodium and calcium channels, glutamate receptors, monoamines and neurotrophic factors; however, treatment is often insufficient. A mechanism-based treatment approach is suggested to improve treatment. Valid and reliable tools to assess various symptoms and signs in neuropathic pain and knowledge of drug mechanisms are prerequisites for pursuing this approach. The present review summarizes mechanisms of neuropathic pain, targets of currently used drugs, and measures used in neuropathic pain trials.
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In this literature review, the mechanisms underlying pain associated with osteoarthritis (OA) are discussed, along with evidence for the efficacy of medications thought to act centrally to relieve OA pain. We survey the cascade of events from inflammation to activation of nociceptive and neuropathic pathways, to the development and maintenance of central and peripheral sensitization. Preclinical and clinical evidence for the sensitization hypothesis is discussed, along with recently identified genetic variations that may increase sensitivity to pain in patients with OA. Evidence is presented for the efficacy of centrally acting analgesics for OA pain (opioids, antiepileptics, tricyclic antidepressants, and serotonin/norepinephrine receptor inhibitors).
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There is increasing evidence that chronic pain problems are characterised by alterations in brain structure and function. Chronic back pain is no exception. There is a growing sentiment, with accompanying theory, that these brain changes contribute to chronic back pain, although empirical support is lacking. This paper reviews the structural and functional changes of the brain that have been observed in people with chronic back pain. We cast light on the clinical implications of these changes and the possibilities for new treatments but we also advise caution against concluding their efficacy in the absence of solid evidence to this effect.
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Widespread pain has negative influence on outcome in low back pain (LBP) patients. Tender point (TP) examination is a standardized examination method to estimate diffuse tenderness. To assess diffuse tenderness by means of a standardized TP examination and to analyse for associations between the number of TPs and spinal structural changes as well as psycho-social factors. Patients sick-listed 3-16 weeks due to LBP with or without sciatica completed a questionnaire and went through a clinical low back examination and TP examination. Of 326 patients 111 had verified nerve root affection and 215 had non-specific LBP with or without radiating pain. Disc height reductions were estimated on lateral X-rays. Multivariate logistic regression analysis showed that more than 8 TPs were strongly negatively associated with disc degeneration (Odds Ratio (OR) 0.58 (0.40-84), 95% Confidence Interval (CI): 0.39-0.84, p=0.004) and verified nerve root affection (OR 0.15 (0.04-0.54), p=0.004) and were positively associated with number of years since first episode of LBP (OR 1.05, CI: 1.01-1.09, p=0.009). Furthermore, more than 8 TPs were positively associated with widespread pain, female sex and bodily distress. With all patients included, bodily distress and the number of tender points were positively associated with the intensity of LBP, but disc degeneration was only positively associated with LBP in patients with less than 6 TPs. The pain in patients with diffuse tenderness was rarely related to disc degeneration or nerve root affection, rather it may be caused by disturbed pain regulation.
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We discuss the issue of identifiability of models for multiple dichotomous diagnostic tests in the absence of a gold standard (GS) test. Data arise as multinomial or product-multinomial counts depending upon the number of populations sampled. Models are generally posited in terms of population prevalences, test sensitivities and specificities, and test dependence terms. It is commonly believed that if the degrees of freedom in the data meet or exceed the number of parameters in a fitted model then the model is identifiable. Goodman (1974, Biometrika 61, 215-231) established that this was not the case a long time ago. We discuss currently available models for multiple tests and argue in favor of an extension of a model that was developed by Dendukuri and Joseph (2001, Biometrics 57, 158-167). Subsequently, we further develop Goodman's technique, and make geometric arguments to give further insight into the nature of models that lack identifiability. We present illustrations using simulated and real data.