Article

Mechanisms-based classifications of musculoskeletal pain: Part 1 of 3: Symptoms and signs of central sensitisation in patients with low back (+/- leg) pain

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Abstract

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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... Smart et al. (2012a) [36] reported that central sensitization is characterized by widespread pain, generalized hyperalgesia, and symptoms that are disproportionate to mechanical triggers or identifiable tissue damage. Patients often lack clear anatomical patterns, and their pain presentation includes hypersensitivity and non-mechanical aggravating factors. ...
... Central sensitization emerged as the most challenging mechanism to identify and manage. Studies by Smart et al. (2012a) [36], Nijs et al. (2015) [24], and Sanzarello et al. (2016) [39] emphasized the presence of widespread pain, generalized hyperalgesia, and symptoms that are disproportionate to the extent of tissue injury or mechanical stress. Patients with central sensitization also exhibited hypersensitivity to non-noxious stimuli and inconsistent responses to physical assessments, reflecting the altered pain processing within the central nervous system. ...
... Patients with central sensitization also exhibited hypersensitivity to non-noxious stimuli and inconsistent responses to physical assessments, reflecting the altered pain processing within the central nervous system. Smart et al. (2012a) [36] validated these findings through a statistical model, achieving high sensitivity (91.8%) and specificity (97.7%) for recognizing central sensitization based on symptom clusters. Similarly, Nijs et al. (2015) [24] proposed a clinical algorithm that integrates subjective and objective assessments, such as pain distribution, neurodynamic testing, and advanced tools such as Quantitative Sensory Testing (QST) and the Central Sensitisation Inventory (CSI). ...
Article
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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.
... " 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. ...
... 17 Finally, nociplastic pain is due to altered nociception despite no evidence of tissue damage activating peripheral nociceptors, and it is likely secondary to central sensitization. 13,16,19 Key elements of the clinical cluster of nociplastic pain include 1) disproportionate pain relative to the injury or pathology, 2) disproportionate, nonmechanical pattern of pain provocation from aggravating and easing factors, 3) presence of maladaptive biopsychosocial variables, and 4) diff use pain on palpation. 14,16 ■ Clinical manifestations In an eff ort to minimize cost and keep management of LBP patient-centered, clinical practice guidelines suggest classifying LBP based on a clustering of signs and symptoms. ...
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. ...
... specificity 97.7%, 95% CI: 95.6-99.0) [28]. Nijs and colleagues, described information obtained from the medical diagnosis, combined with the medical history of the patient, as well as the clinical examination and the analysis of the treatment response in order to recognize CS [16]. ...
... Another key part of this study is the correlation between various patient characteristics and presentation of CS. The CSI is not commonly used in clinical practice as a screening tool and clinicians are advised to use subjective and objective clues to determine the clinical presence of CS [24,28]. It is argued that following a thorough subjective interview and physical examination, the PT should be able to identify various signs and symptoms to determine the appropriate pain mechanism, which in turn should drive decision-making for the treatment. ...
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.
... Participants with LBP were classified based on their clinical presentation of LBP according to the presumed underlying pain mechanisms, posture and movement profiles and cognitive/psychological features before the experimental procedures began (Fig. 1). The likely underlying pain mechanism for LBP was determined based on detailed assessment of the characteristics of LBP following recommendations of clinically validated methods (Smart et al., 2012a;Nijs et al., 2015;Shraim et al., 2020) (Table 1) and an in-depth interview to explore the clinical indicators of NcP and NpP mechanisms (Smart et al., 2010;2011;Smart et al., 2012a;. This included injury history, pain behaviour (24-hour pattern, aggravating and pain easing factors), questions about lifestyle, daily habits (work status, exercise habits, leisure activities, family support, etc.). ...
... Participants with LBP were classified based on their clinical presentation of LBP according to the presumed underlying pain mechanisms, posture and movement profiles and cognitive/psychological features before the experimental procedures began (Fig. 1). The likely underlying pain mechanism for LBP was determined based on detailed assessment of the characteristics of LBP following recommendations of clinically validated methods (Smart et al., 2012a;Nijs et al., 2015;Shraim et al., 2020) (Table 1) and an in-depth interview to explore the clinical indicators of NcP and NpP mechanisms (Smart et al., 2010;2011;Smart et al., 2012a;. This included injury history, pain behaviour (24-hour pattern, aggravating and pain easing factors), questions about lifestyle, daily habits (work status, exercise habits, leisure activities, family support, etc.). ...
... Using these criteria, participants were classified into the following groups: (i) nociceptive pain group (NcP); with likely ongoing nociceptive contribution linked to flexion pattern (NcP-FP, n=13) or active extension pattern (NcP-AEP, n=6) MCI and psychosocial features within "normal" limits; (ii) nociplastic pain group (NpP, n=4) which included those with absence of mechanical pain behaviour and predominant features of central sensitisation (Smart et al., 2010;2011;Smart et al., 2012a; and psychosocial features above normal limits; and (iii) mixed pain group (MP) with features of both NcP and NpP, that included psychosocial features outside normal limits (n=5). Participants were classified before the experimental measures began. ...
Article
Full-text available
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.
... 66,67 Depression and anxiety are associated with, or may aggravate symptoms suggestive of central sensitization and nociplastic pain. 9,17,[68][69][70] The validated Spanish versions of these questionnaires were filled at baseline and at 4 weeks. Both questionnaires have high internal consistency (Cronbach's α = .89 ...
... 71 In addition, CPLBP was classified as proportionate or disproportionate, with a discrete or diffuse anatomical distribution, following criteria defined previously. 13,70 Diffuse pain may be reflective of spreading hyperalgesia, suggestive of nociplastic pain. 9,11,72 The classification of symptoms as proportionate or disproportionate was based on the pattern of pain provocation and aggravation, to rule in or out nociceptive pain versus nociplastic pain (suggestive of central mechanisms). ...
Article
Chronic primary low back pain (CPLBP) refers to low back pain that persists over three months, that cannot be explained by another chronic condition, and that is associated with emotional distress and disability. Previous studies have shown that spinal manipulative therapy (SMT) is effective to relieve CPLBP, but the underlying mechanisms remain elusive. This randomized placebo-controlled dual-blind mixed experimental trial (NCT05162924) aimed to investigate the efficacy of SMT to improve CPLBP and its underlying mechanisms. Ninety-eight individuals with CPLBP and 49 controls were recruited. Individuals with CPLBP received SMT (n=49) or a control intervention (n=49), twelve times over four weeks. The primary outcomes were CPLBP intensity (0-100 on a numerical rating scale) and disability (Oswestry Disability Index). Secondary outcomes included pressure pain thresholds in four body regions, pain catastrophizing, central sensitization inventory, depressive symptoms, and anxiety scores. Individuals with CPLBP showed widespread mechanical hyperalgesia (p<.001) and higher scores for all questionnaires (p<.001). SMT reduced pain intensity compared with the control intervention (mean difference: -11.7 [95% CI, -11.0 to -12.5], p=.01), but not disability (p=.5). Similar mild to moderate adverse events were reported in both groups. Mechanical hyperalgesia at the manipulated segment was reduced after SMT compared with the control intervention (p<.05). Pain catastrophizing was reduced after SMT compared with the control intervention (p<.05), but this effect was not significant after accounting for changes in clinical pain. Although the reduction of segmental mechanical hyperalgesia likely contributes to the clinical benefits of SMT, the role of pain catastrophizing remains to be clarified. PERSPECTIVE This randomized controlled trial found that twelve sessions of spinal manipulative therapy yield greater relief of chronic primary low back pain than a control intervention. These clinical effects were independent of expectations, and accompanied by an attenuation of hyperalgesia in the targeted segment and a modulation of pain catastrophizing.
... Central sensitization (CS) has recently been recognized as a potential pathophysiological cause of several chronic pain disorders, including chronic LBP (CLBP), chronic neck pain, myofascial pain syndrome, fibromyalgia, temporomandibular joint disorder, irritable bowel syndrome, interstitial cystitis, and tension-type headache [12][13][14][15][16]. These disorders have been classified on the mentalphysical health spectrum as psychosomatic, medically unexplained, or due to functional or somatic factors [12,14,15]. ...
... Central sensitization (CS) has recently been recognized as a potential pathophysiological cause of several chronic pain disorders, including chronic LBP (CLBP), chronic neck pain, myofascial pain syndrome, fibromyalgia, temporomandibular joint disorder, irritable bowel syndrome, interstitial cystitis, and tension-type headache [12][13][14][15][16]. These disorders have been classified on the mentalphysical health spectrum as psychosomatic, medically unexplained, or due to functional or somatic factors [12,14,15]. CS involves an increased responsiveness of the central and/or peripheral nervous system circuits [12] and has been associated with chronic pain development [13]. ...
Article
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Background Controversy remains regarding predictors of surgical outcomes for patients with lumbar spinal stenosis (LSS). Pain sensitization may be an underlying mechanism contributing to LSS surgical outcomes. Further, obesity is associated with dissatisfaction and poorer outcomes after surgery for LSS. Therefore, this study aimed to examine the relationship between central sensitization (CS), visceral fat, and surgical outcomes in LSS. Methods Patients with LSS were categorized based on their central sensitization inventory (CSI) scores into low- (CSI < 40) and high- (CSI ≥ 40) CSI subgroups. The participants completed clinical outcome assessments preoperatively and 12 months postoperatively. Results Overall, 60 patients were enrolled in the study (28 men, 32 women; mean age: 62.1 ± 2.8 years). The high-CSI group had significantly higher mean low back pain (LBP), leg pain, and leg numbness visual analogue scale (VAS) scores than the low-CSI group (p < 0.01). The high-CSI group had a significantly higher mean visceral fat area than the low-CSI group (p < 0.01). Postoperatively, LBP VAS score was significantly worse in the high-CSI group. Relative to preoperatively, postoperative leg pain and leg numbness improved significantly in both groups. Conclusions We believe that neuro decompression can be effective for LSS surgical outcomes in patients with CS; nonetheless, it should be approached with caution owing to the potential for worsening LBP. Additionally, visceral fat is an important indicator suggesting the involvement of CS.
... One of the proposed classification systems stratifies patients into specific subgroups according to pain mechanisms (nociceptive, neuropathic or central sensitisation). [5][6][7][8][9][10] It has been suggested that a large proportion of patients with CLBP presents chronic primary pain, which has been linked to altered nociceptive processing. 11 12 Among the phenomena that may underlie this aberrant processing, central sensitisation (CS) is likely the predominant ...
... The Pain Catastrophizing Scale (PCS) and CSI will be completed before the beginning of the treatment (baseline) and at a single follow-up after the 12th treatment session (see figure 2B and F). 78 79 The PCS will be used to identify specific pain cognitions that are frequently present in patients with a CS phenotype; this measure will be used to evaluate the association of CLBP with psychosocial factors described by Smart et al. 5 When combined with a clinical presentation suggestive of CS, 35 the CSI is a useful tool to identify patients with certain pain mechanisms compatible with CS, particularly when using the cut-off value of 40 points. 80 Both these scores will be examined as predictors due to their intrinsic association with a CS phenotype. ...
Article
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Introduction Chronic low back pain (CLBP) is a highly prevalent and disabling condition. Identifying subgroups of patients afflicted with CLBP is a current research priority, for which a classification system based on pain mechanisms was proposed. Spinal manipulative therapy (SMT) is recommended for the management of CLBP. Yet, little data are available regarding its mechanisms of action, making it difficult to match this intervention to the patients who may benefit the most. It was suggested that SMT may influence mechanisms associated with central sensitisation. Therefore, classifying patients with CLBP according to central sensitisation mechanisms may help predict their response to SMT. Methods and analysis This protocol describes a randomised placebo-controlled trial aiming to examine which variables linked to central sensitisation may help predict the clinical response to SMT in a cohort of patients with CLBP. One hundred patients with chronic primary low back pain will be randomised to receive 12 sessions of SMT or placebo SMT over a 4-week period. Pain intensity and disability will be assessed as primary outcomes after completing the 4-week treatment (primary endpoint), and at 4-week and 12-week follow-ups. Baseline values of two pain questionnaires, lumbar pressure pain thresholds, concentrations of an inflammatory cytokine and expectations of pain relief will be entered as predictors of the response to SMT in a multiple regression model. Changes in these variables after treatment will be used in a second multiple regression model. The reference values of these predictors will be measured from 50 age and sex-matched healthy controls to allow interpretation of values in patients. Mixed analyses of variance will also be conducted to compare the primary outcomes and the predictors between groups (SMT vs placebo) over time (baseline vs post-treatment). Ethics and dissemination Ethical approval was granted by the Fundación Jiménez Díaz Clinical Research Ethics Committee. Trial registration number NCT05162924 .
... However, there are few reports on the association between visceral fat and chronic LBP (CLBP). Central sensitisation (CS) has recently been recognised as a possible pathophysiological cause of several chronic pain disorders, including CLBP, chronic neck pain, myofascial pain syndrome, fibromyalgia, temporomandibular joint disorder, irritable bowel syndrome, interstitial cystitis, and tension-type headache [22][23][24][25][26][27]. These disorders have been classified on the mental-physical health spectrum as psychosomatic, medically unexplained, or arising due to functional or somatic factors [22,25,26]. ...
... Central sensitisation (CS) has recently been recognised as a possible pathophysiological cause of several chronic pain disorders, including CLBP, chronic neck pain, myofascial pain syndrome, fibromyalgia, temporomandibular joint disorder, irritable bowel syndrome, interstitial cystitis, and tension-type headache [22][23][24][25][26][27]. These disorders have been classified on the mental-physical health spectrum as psychosomatic, medically unexplained, or arising due to functional or somatic factors [22,25,26]. CS involves the increased responsiveness of the central and/or peripheral nervous system circuits [22] and has been associated with the development of CLBP [23,24], although the association between CLBP and CS remains unknown. ...
Article
Background: Pain sensitization may be one of the mechanisms contributing to chronic low back pain (CLBP). Objective: To evaluate the association between visceral fat, CLBP, and central sensitization (CS); describe the relationship between low back pain (LBP) intensity and CS; and identify possible correlation between visceral fat and LBP intensity. Methods: Patients with CLBP were divided using their CS inventory (CSI) scores into low- (CSI < 40) and high-CSI (CSI ⩾ 40) subgroups. We compared computed tomography (CT) measurements and scores for association with pain according to the visual analogue scale (VAS) between the two groups. Results: The low-CSI and the high-CSI groups had 47 patients (67.1%; 21 men, 26 women) and 23 patients (32.9%; 11 men and 12 women), respectively. The high-CSI group had a significantly higher mean VAS score (p< 0.01) and estimated mean visceral fat area (p< 0.05) than the low-CSI group. There was a moderate positive correlation between VAS score and visceral fat (standardised partial regression coefficient: 0.659, p< 0.01) in the high-CSI group according to multiple linear regression analysis adjusted for age and sex. Conclusions: Visceral fat is associated with CLBP, regardless of sex or age, and may be a potential therapeutic target for CLBP with CS.
... They reported an expert consensus-derived list of clinical criteria suggestive of a clinical dominance of nociceptive, peripheral neuropathic and 'central' mechanisms of musculoskeletal pain [46]. This pioneering work was expanded with the same group reporting a study of 64 patients with low back and leg pain, where they identified key symptoms that allowed clinicians to differentiate with a high discriminative ability [47] CS pain from nociceptive and neuropathic pain [48]: disproportionate, nonmechanical, 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 and diffuse/nonanatomic areas of pain/tenderness on palpation. ...
... Hence, both sets of criteria stress the importance of differentiating from nociceptive pain by excluding the possibility that nociception is the main driver of the experienced pain and consequently used this as a mandatory criterion. Of note is also that three out of four of the symptoms identified by Smart et al. in 2012 [48] as having the ability to differentiate between peripheral neuropathic, nociceptive and CS pain are included (in other wordings) in the 2021 IASP clinical criteria for nociplastic pain. It is worth mentioning that more than one pain phenotype can present. ...
Article
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Recently, the International Association for the Study of Pain (IASP) released clinical criteria and a grading system for nociplastic pain affecting the musculoskeletal system. These criteria replaced the 2014 clinical criteria for predominant central sensitization (CS) pain and accounted for clinicians' need to identify (early) and correctly classify patients having chronic pain according to the pain phenotype. Still, clinicians and researchers can become confused by the multitude of terms and the variety of clinical criteria available. Therefore, this paper aims at (1) providing an overview of what preceded the IASP criteria for nociplastic pain ('the past'); (2) explaining the new IASP criteria for nociplastic pain in comparison with the 2014 clinical criteria for predominant CS pain ('the present'); and (3) highlighting key areas for future implementation and research work in this area ('the future'). It is explained that the 2021 IASP clinical criteria for nociplastic pain are in line with the 2014 clinical criteria for predominant CS pain but are more robust, comprehensive, better developed and hold more potential. Therefore, the 2021 IASP clinical criteria for nociplastic pain are important steps towards precision pain medicine, yet studies examining the clinimetric and psychometric properties of the criteria are urgently needed.
... CS is driven by neuroinflammation in the Central Nervous System and Peripheral Nervous System, which reaches higher brain regions involved in the emotional and cognitive modulation of pain (for reviews) 41,42 . Several musculoskeletal diseases and conditions present CS, such as osteoarthritis 43 , patellofemoral pain 44 , temporomandibular dysfunction 45 , shoulder pain 46 , tendinopathies 47 , fibromyalgia 40 , low back pain 48 and rheumatoid arthritis 49 . CS is influenced by neuroinflammation, so it becomes a common process in pain with nociceptive and neuropathic components [50][51][52][53] . ...
Article
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BACKGROUND AND OBJECTIVES There are conditions in which chronic musculoskeletal pain is present without apparent tissue damage, such as fibromyalgia or non-specific low back pain. In these cases, understanding the disease and treatment are challenges for patients, professionals and health services. Therefore, the aim of this study was to carry out a narrative review on chronic musculoskeletal pain, discuss current definitions and classifications and present different management strategies in order to contribute to clinical practice. CONTENTS Chronic musculoskeletal pain, without apparent injury, is now considered a disease and has been updated in the International Code of Diseases 11 (ICD-11), being called primary chronic musculoskeletal pain. The main mechanism of this type of pain is nociplastic, in which there is no clear evidence of actual or potential tissue damage, causing the activation of peripheral nociceptors or evidence of disease or injury to the somatosensory system that causes the pain. CONCLUSION Chronic musculoskeletal pain is now classified into subgroups: primary chronic pain, in which pain is understood as a disease; and secondary chronic pain, in which pain is a symptom that arises as part of a disease process. Emotional distress and functional disability are characteristic, but not exclusive, to primary chronic musculoskeletal pain, in which there are no tissue lesions or other diagnosis that explain the pain. Treatment strategies should be multimodal and multidisciplinary. Keywords: Chronic pain; Models; Models biopsychosocial; Musculoskeletal pain
... 1,2,5,20 This process is labeled as a nociplastic pain , with a clinical presentation of disproportionate pain, diffuse tenderness to palpation, disproportionate aggravating and easing factors, and psychosocial issues -typically high levels of fear, fear-avoidance, depression, and pain catastrophizing. 27 ...
Article
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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
... 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]. ...
Research
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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.
... 39 In addition, the BACPAP consortium's consensus recommendations are supported by the findings from two Delphi studies on features and assessment findings that are unique to at least one of the pain phenotypes, 7,41 and an original research study of 464 patients with low back pain on predictors that would today be associated with nociplastic, versus peripheral neuropathic and nociceptive low back pain. 110 The scientific foundation for, and limitations of the seven steps of the BACPAP consortium's consensus recommendations for pain phenotyping in the low back pain population are outlined in the appendix (pp 2-4). Neither individual features or methods, nor the BACPAP consortium's consensus recommendations proposed here are yet validated as a gold standard framework for pain phenotyping in the low back pain population. ...
Article
The potential to classify low back pain as being characterised by dominant nociceptive, neuropathic, or nociplastic mechanisms is a clinically relevant issue. Preliminary evidence suggests that these low back pain phenotypes might respond differently to treatments; however, more research must be done before making specific recommendations. Accordingly, the low back pain phenotyping (BACPAP) consortium was established as a group of 36 clinicians and researchers from 13 countries (five continents) and 29 institutions, to apply a modified Nominal Group Technique methodology to develop international and multidisciplinary consensus recommendations to provide guidance for identifying the dominant pain phenotype in patients with low back pain, and potentially adapt pain management strategies. The BACPAP consortium's recommendations are also intended to provide direction for future clinical research by building on the established clinical criteria for neuropathic and nociplastic pain. The BACPAP consortium's consensus recommendations are a necessary early step in the process to determine if personalised pain medicine based on pain phenotypes is feasible for low back pain management. Therefore, these recommendations are not ready to be implemented in clinical practice until additional evidence is generated that is specific to these low back pain phenotypes.
... 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.
... [14][15][16][17][18] A further, rather clinical characteristic of sensitization within the central nervous system is a spread of pain beyond the expected anatomical region of pathology. 6 This has been observed in various chronic pain conditions such as neuropathic pain after spinal cord injury, 19 chronic pelvic pain, 20 osteoarthritis, 21 low back pain, 22 and CRPS. 23 In particular, CRPS patients showed three different patterns of pain distribution, that is, continuous spreading, independent spreading, and mirror-image spreading. ...
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Objective: Widespread pain hypersensitivity and enhanced temporal summation of pain (TSP) are commonly reported in patients with complex regional pain syndrome (CRPS) and discussed as proxies for central sensitization. This study aimed to directly relate such signs of neuronal hyperexcitability to the pain phenotype of CRPS patients. Methods: Twenty-one CRPS patients and 20 healthy controls (HC) were recruited. The pain phenotype including spatial pain extent (assessed in % body surface) and intensity were assessed and related to widespread pain hypersensitivity, TSP, and psychological factors. Quantitative sensory testing (QST) was performed in the affected, the contralateral and a remote (control) area. Results: CRPS patients showed decreased pressure pain thresholds in all tested areas (affected: t(34)=4.98, p < 0.001, contralateral: t(35)=3.19, p = 0.005, control: t(31)=2.65, p = 0.012). Additionally, patients showed increased TSP in the affected area (F(3,111)=4.57, p = 0.009) compared to HC. TSP was even more enhanced in patients with a high compared to a low spatial pain extent (F(3,51)=5.67, p = 0.008), suggesting pronounced spinal sensitization in patients with extended pain patterns. Furthermore, the spatial pain extent positively correlated with the Bath Body Perception Disturbance Scale (ρ = 0.491; p = 0.048). Conclusion: Overall, we provide evidence that the pain phenotype in CRPS, i.e., spatial pain extent, might be related to sensitization mechanism within the central nociceptive system. This study points towards central neuronal excitability as a potential therapeutic target in patients with more widespread CRPS.
... 7 These efforts have identified predictors for severe disease such as poor physical function, depression, and older age. 12 However, for a heterogeneous, multidimensional disease like LBP, a comprehensive screen of personal attributes Machine learning is a powerful analytic tool that recognizes patterns in data without explicit programming. 13 Unlike traditional regression, machine learning can identify complex and nonlinear relationships between factors to identify phenotypes in an unbiased manner and generate sophisticated predictions. ...
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Background: Low back pain (LBP) is a heterogeneous disease with biological, physical, and psychosocial etiologies. Models for predicting LBP severity and chronicity have not made a clinical impact, perhaps due to difficulty deciphering multidimensional phenotypes. In this study, our objective was to develop a computational framework to comprehensively screen metrics related to LBP severity and chronicity and identify the most influential. Methods: We identified individuals from the observational, longitudinal Osteoarthritis Initiative cohort (N = 4796) who reported LBP at enrollment (N = 215). OAI descriptor variables (N = 1190) were used to cluster individuals via unsupervised learning and uncover latent LBP phenotypes. We also developed a dimensionality reduction algorithm to visualize clusters/phenotypes using Uniform Manifold Approximation and Projection (UMAP). Next, to predict chronicity, we identified those with acute LBP (N = 40) and persistent LBP over 8 years of follow-up (N = 66) and built logistic regression and supervised machine learning models. Results: We identified three LBP phenotypes: a "high socioeconomic status, low pain severity group", a "low socioeconomic status, high pain severity group", and an intermediate group. Mental health and nutrition were also key clustering variables, while traditional biomedical factors (e.g., age, sex, BMI) were not. Those who developed chronic LBP were differentiated by higher pain interference and lower alcohol consumption (a correlate to poor physical fitness and lower soceioeconomic status). All models for predicting chronicity had satisfactory performance (accuracy 76%-78%). Conclusions: We developed a computational pipeline capable of screening hundreds of variables and visualizing LBP cohorts. We found that socioeconomic status, mental health, nutrition, and pain interference were more influential in LBP than traditional biomedical descriptors like age, sex, and BMI.
... Another relevant factor in central sensitization is the cognitive-emotional aspects of pain processing, e.g. magnification and rumination, which have been determined a relevant factor in central sensitization (Brosschot, 2002;Smart et al., 2012). Our results are in line with these findings, indicating a positive correlation between TSP magnitude and PCS score. ...
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Background: Central sensitization is considered a key mechanism underlying neuropathic pain (NP) after spinal cord injury (SCI). Methods: Two novel proxies for central sensitization were investigated in thoracic SCI subjects with (SCI-NP) and without NP (SCI-nonNP) compared to healthy controls (HC). Specifically, temporal summation of pain (TSP) was investigated by examining pain ratings during a 2-min tonic heat application to the volar forearm. Additionally, palmar heat-induced sympathetic skin responses (SSR) were recorded in order to reveal changes in pain-autonomic interaction above the lesion level. Pain extent was assessed as the percentage of body area and the number of body regions being affected by NP. Results: Enhanced TSP was observed in SCI-NP (+66%) compared to SCI-nonNP (-75%, p=0.009) and HC (-59%, p=0.021). In contrast, no group differences were found (p=0.685) for SSR habituation. However, pain extent in SCI-NP was positively correlated with deficient SSR habituation (body area: r=0.561, p=0.024; body regions: r=0.564, p=0.023). Conclusions: These results support the value of TSP and heat-induced SSRs as proxies for central sensitization in widespread neuropathic pain syndromes after SCI. Measures of pain-autonomic interaction emerged as a promising tool for the objective investigation of sensitized neuronal states in chronic pain conditions.
... [144] y validez discriminativa (LR positivo 40.6, IC 20.4-80.8) [145] . No se pueden hacer conclusiones basadas en la evidencia presente, aunque nuestros criterios sugeridos para ser utilizados en futuros estudios diagnósticos parecen tener validez y se han informado aspectos prometedores de la validez de constructo y nivel de confiabilidad entre evaluadores. ...
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INTRODUCCIÓN Los resultados del examen clínico se utilizan en la atención primaria para brindar un diagnóstico inicial a los pacientes con dolor lumbar y síntomas relacionados con las piernas. El propósito de este estudio fue desarrollar la mejor evidencia de Reglas de Diagnóstico Clínico (CDR, por sus siglas en inglés) para la identificación de los trastornos anatomopatológicos más co-munes en la columna lumbar; es decir, discos intervertebrales, articulacio-nes sacroilíacas, articulaciones facetarias, huesos, músculos, raíces nervio-sas, tejido nervioso periférico y sensibilización del sistema nervioso central. Métodos: se combinó una estrategia de búsqueda electrónica sensible uti-lizando las bases de datos MEDLINE, EMBASE y CINAHL, con búsqueda manual y seguimiento de citas para identificar los estudios a elegir. Los cri-terios de inclusión fueron: personas con dolor lumbar con o sin síntomas re-lacionados con las piernas, antecedentes o hallazgos de exámenes físicos adecuados para su uso en atención primaria, comparación con estándares de referencia aceptables e informes estadísticos que permitieran el cálculo del valor diagnóstico. Dos revisores realizaron, de forma independiente, las evaluaciones de calidad utilizando la herramienta Quality Assessment of Diagnostic Accurancy Studies (Evaluación de Calidad de los Estudios de Precisión Diagnóstica). Se incluyeron los hallazgos del examen clínico que fueron investigados por al menos dos estudios y se consideraron para la CDR los resultados que cumplieron con nuestro umbral predefinido de un LR positivo ≥ 2 o LR negativo ≤ 0.5. Resultados: sesenta y cuatro estudios cumplieron con los criterios elegi-bles. Pudimos construir CDRs prometedores para el disco intervertebral sintomático, la articulación sacroilíaca, la espondilolistesis, la hernia discal con afección de la raíz nerviosa y la estenosis espinal. Las pruebas clínicas individuales parecieron menos útiles que los grupos de pruebas que están más en línea con la toma de decisión clínica. Conclusiones: esta es la primera revisión sistemática de estudios de preci-sión diagnóstica que evalúa los hallazgos de los exámenes clínicos por su capacidad para identificar los trastornos anatomopatológicos más comu-nes en la columna lumbar. En algunas categorías de diagnóstico tenemos evidencia suficiente para recomendar una CDR. En otras, sólo tenemos evi-dencia preliminar que necesita ser probada en estudios futuros. La mayoría de los hallazgos fueron probados en la atención secundaria o terciaria. Por lo tanto, la precisión de los hallazgos en un entorno de atención primaria aún no se ha confirmado.
... Nyeri punggung bawah merupakan sebuah gejala dimana memiliki banyak penyebab yang dapat berkontribusi dalam peningkatan nyeri tersebut (Maher et al., 2017). Nyeri yang dirasakan dapat berasal dari kelainan pada struktur anatomi seperti saraf, otot, sendi, dan diskus intervertebralis (Smart et al., 2012). Nyeri dapat bertambah saat melakukan aktivitas yang lama (Pillai & Haral, 2018). ...
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Nyeri punggung bawah tidak hanya terjadi karena adanya patofisiologi dari struktur anatomi pada tubuh khususnya punggung ( back ) tetapi juga bisa dikarenakan oleh sikap, kepercayan, dan perilaku. Keluhan pada individu terkait nyeri punggung bawah dapat disebabkan oleh beberapa faktor seperti biologi, psikologi dan sosial dari individu tersebut. Faktor biopsikososial pada individu dengan keluhan nyeri punggung bawah dapat dipengaruhi oleh intervensi yang berkaitan dengan rehabilitasi biopsikososial dimana dapat meningkatkan kualitas hidup individu. Kualitas hidup merujuk suatu keadaan fisik, emosional dan sosial individu serta kemampuan aktivitas pada kehidupanya sehari-hari. Kualitas hidup dapat dinilai secara kondisi fisik, psikologis, hubungan sosial dan lingkunganya. Tujuan dari studi ini adalah mengetahui adanya pengaruh intervensi biopsikososial terhadap kualitas hidup pada individu dengan keluhan nyeri punggung bawah. Metode yang digunakan pada studi ini yaitu literature review dimana jurnal yang akan diteliti menggunakan jenis penelitian randomized controlled trial. Artikel yang digunakan berdasarkan pencarian dari search engine dengan mempertimbangkan kriteria tertentu. Proses appraisal menggunakan PICO yang selanjutnya dilakukan appraisal dengan skala PEDro. Berdasarkan hasil review terdapat empat artikel dengan bias rendah dan dua artikel dengan moderate . Hasil review dari artikel dengan bias rendah menghasilkan simpulan bahwa faktor biopsikosial terbukti mempengaruhi kualitas hidup individu dengan keluhan nyeri punggung bawah.
... 81 ) and auto BUSTER v.2.10.2 (ref. 82 ) followed by manual examination and rebuilding of the refined coordinates in the program COOT 76 using both |2Fo|-|Fc| and |Fo|-|Fc| maps. Residues 7-18 of the N terminus are disordered and not visible in the electron density maps, which were not modeled. ...
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The technique of cryogenic-electron microscopy (cryo-EM) has revolutionized the field of membrane protein structure and function with a focus on the dominantly observed molecular species. This report describes the structural characterization of a fully active human apelin receptor (APJR) complexed with heterotrimeric G protein observed in both 2:1 and 1:1 stoichiometric ratios. We use cryo-EM single-particle analysis to determine the structural details of both species from the same sample preparation. Protein preparations, in the presence of the endogenous peptide ligand ELA or a synthetic small molecule, both demonstrate these mixed stoichiometric states. Structural differences in G protein engagement between dimeric and monomeric APJR suggest a role for the stoichiometry of G protein-coupled receptor- (GPCR-)G protein coupling on downstream signaling and receptor pharmacology. Furthermore, a small, hydrophobic dimer interface provides a starting framework for additional class A GPCR dimerization studies. Together, these findings uncover a mechanism of versatile regulation through oligomerization by which GPCRs can modulate their signaling. Cryo-EM analysis of the human apelin receptor activated by either the endogenous peptide ligand or a potent synthetic small-molecule agonist reveals a mixture of homodimer and monomer organizations shedding light on a versatile regulation mechanism.
... [28][29][30][31][32][33] Furthermore, a widespread or increased spatial distribution of symptoms as well as a disproportionate pattern of pain provocation are clinical features described as indicators of altered central somatosensory processing. 34 Spatial distribution of symptoms can be easily evaluated by the Margolis Pain Diagram by calculating the percentage pain surface area. 35 A Visual Analog Scale (VAS) may be used to evaluate the pattern of pain provocation. ...
Article
Purpose: Pain and sensory disturbances are common side effects of breast cancer treatment. Differential somatosensory functioning may reflect distinct pathophysiological backgrounds and therapeutic needs. Aim was to examine whether questionnaires evaluating signs and symptoms related to somatosensory functioning correlate sufficiently with quantitative sensory testing (QST) in breast cancer survivors to warrant consideration for somatosensory profiling in clinical practice. Methods: One year after breast cancer surgery, 147 women underwent QST and completed following questionnaires: Douleur Neuropathique en 4 questions (DN4), Central Sensitization Inventory, Margolis Pain Diagram and Visual Analog Scales (VAS). Associations between the questionnaires and QST were evaluated using Spearman correlation coefficients (rs). Results: Significant but weak (rs < 0.30) correlations were found between total DN4 score and QST results at the inner upper arm for detection of sharp stimuli (rs = 0.227), cold stimuli (rs = -0.186), and painful heat stimuli (rs = 0.179), as well as between QST evaluating conditioned pain modulation and the Margolis Pain Diagram on one hand (rs = 0.176) and minimum-maximum pain intensity differences (VAS) on the other (rs = -0.170). Conclusion: Questionnaires evaluating signs and symptoms related to somatosensory functioning are insufficient for somatosensory profiling. Although somatosensory profiling may be valuable in a mechanism-based management, more research on the most appropriate clinical tools is needed.IMPLICATIONS FOR REHABILITATIONClinicians should be able to recognize that patients with persistent pain or sensory disturbances following breast cancer surgery may have a component of altered somatosensory processing as a significant contributor to their complaint in order to address it appropriately.Somatosensory profiling has yet to be implemented into clinical practice.No evidence-based recommendations can be made on the use of self-reported questionnaires to assess somatosensory processing in a breast cancer population based on the findings of this study.It is suggested to combine information on how individuals process and experience somatosensory stimulation with information from the patient interview or questionnaires to consider which biological, psychological and/or social factors may drive or sustain these neurophysiological processes.
... Pain sensitization is an important pain mechanism in patients with low back pain that relates to increasing pain intensity and disease progression while decreasing quality of life [45,46]. Clinically, pain sensitization can be indirectly measured by quantitative sensory testing (QST) [47,48]. ...
Article
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Background Low back pain is a disability that occurs worldwide. It is a heterogeneous disorder that affects patients with dominant nociceptive, neuropathic, and central sensitization pain. An important pathophysiology of low back pain involves pain sensitization. Various nonoperative interventions are available for treatment, but there is inconclusive evidence on the effectiveness of these interventions for pain sensitization, leading to arbitrary nonoperative treatments for low back pain. Methods We will conduct a systematic review of RCTs evaluating the effectiveness and safety of nonoperative treatment for pain sensitization in patients with low back pain. The primary outcomes will be static quantitative sensory testing, dynamic quantitative sensory testing, and pain algometry. The secondary outcome will be adverse events. We will search the PubMed, Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Library databases. Two independent authors will screen the titles and abstracts, review full texts, extract data, assess the risk of bias, and evaluate the quality of evidence. We will qualitatively and quantitatively synthesize the results using a random effects model for meta-analysis. Discussion This systematic review aims to provide evidence regarding which treatment, if any, provides the greatest benefit for pain sensitization and safety among patients with low back pain. Evidence synthesized from this systematic review will inform clinical practice and further research. Since there is still a small amount of research, additional studies might need to be conducted in the future. Systematic review registration Submitted to PROSPERO on March 20, 2021, CRD42021244054
... Chronic pain was also associated with MP. The development and maintenance of chronic pain depend on a neurochemical alteration of the central nervous system [26]. Clarck et al. suggested that acute neurosensory stimulation without long-term recovery of skeletal muscles may be a major cause of neurochemical alteration of the central nervous system [10]. ...
Article
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Orthognathic patients with skeletal class II malocclusion frequently suffer from myofascial pain (MP). Purpose This study aimed to evaluate the prevalence and associated factors of MP in these patients. Methods This cross-sectional study was performed in adult patients with skeletal Class II malocclusion requiring orthognathic surgery. They were divided according to the presence or absence of MP. The predictor variables were craniofacial morphology, sex, temporomandibular disorders, chronic pain, depression, and polymorphisms of dopamine receptors DRD2 (rs6275 and rs6276) and ANKK1 (rs1800497) genes. Data were submitted to statistical analyses using the linear regression model and Poisson regression with a significance level of 0.05. Results Sixty-five individuals were selected, of which 50 (76.92%) were females. A total of 21 (32.3%) patients had MP. Individuals with MP showed a decrease in the mandible gonial angle (p = 0.042) and an increased risk of having temporomandibular joint (TMJ) disc displacement (p = 0.003), TMJ pain (p = 0.030), chronic pain (p = 0.001), and severe depression (p = 0.015). Additionally, individuals carrying AA and AG genotypes in rs6275, and CC genotype in rs6276, were more likely to have MP (p < 0.05). Conclusion In this study, 32.3% of skeletal class II orthognathic patients had MP, which was associated with a decreased gonial angle, TMJ disc displacement, TMJ pain, chronic pain, depression, and polymorphisms in the DRD2 gene.
... If one or more structural differentiation manoeuvres change SLR-provoked symptoms, those symptoms are thought to be at least partly related to neural tissue irritation (Breig and Troup, 1979;Troup, 1981). This interpretation assumes central pain mechanisms are not substantially contributing to the patient's pain experience (Smart et al., 2012a;. ...
Article
Background The passive straight leg raise (SLR) and crossed SLR are recommended tests for lumbar radicular pain. There are no recent reviews of test reliability. Objectives To summarize SLR and crossed SLR reliability in patients with suspected lumbar radicular pain. Design Systematic review with meta-analysis. Method MEDLINE and CINAHL were searched for studies published before April 2021 that reported SLR or crossed SLR reliability in patients with low back-related leg pain. Supplemental analyses also included patients with low back pain only. Study selection, risk of bias assessment (QAREL), and data extraction were performed in duplicate. Kappa, intraclass correlation coefficients, and smallest detectable difference (SDD95) quantified reliability. Meta-analysis was performed when appropriate. Confidence in the evidence was determined by applying GRADE principles. Results/findings Fifteen studies met selection criteria. One-hundred-eighty-nine participants had low back-related leg pain. Four-hundred-thirty-nine were included in supplemental analyses. Meta-analyses showed at least fair inter-rater reliability when a positive SLR required provocation of lower extremity symptoms or pain. SLR reliability was at least moderate when testing included structural differentiation (e.g., ankle dorsiflexion). A low prevalence of positive crossed SLR tests led to wide-ranging reliability estimates. Confidence in the evidence for identifying a positive SLR or crossed SLR was moderate to very low. SDD95 values for different raters measuring SLR range of motion ranged from 13 to 20°. Conclusions Reliability data support testing SLR with structural differentiation manoeuvres. Crossed SLR reliability data are inconclusive. Measurement error likely prohibits using SLR range of motion for clinical decision-making.
... 2022, 12,1970 8 of 10 more probable pain generator [31]. A novel idea in pain medicine is to manage low back pain using patients stratification based on clusters of tests and symptoms or-more importantly-on objective parameters [32]. Thus, our newly proposed diagnostic test that shows pathological autonomic reactivity in diseases that have not been considered before as related to the ANS pathological activity seems interesting. ...
Article
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The Skorupska Protocol (SP) test is a new validated tool used to confirm nociplastic pain related to muscles based on a pathological autonomic nervous system (ANS) activity due to muscle nociceptive noxious stimulation analyzed automatically. Two types of amplified vasomotor response are defined as possible: vasodilatation and vasoconstriction. Until now, amplified vasodilatation among low back leg pain and/or sciatica subjects in response to the SP test was confirmed. This case report presents an unusual vasomotor response to the SP test within the pain zone of a sciatica-like case. Conducted twice, the SP test confirmed amplified vasoconstriction within the daily complaint due to noxiously stimulated muscle-referred pain for the first time. Additionally, a new type of the SP test analysis using MATLAB was presented. The SP test supported by MATLAB seems to be an interesting solution to confirm nociplastic pain related to muscles based on the pathological autonomic reactivity within the lower leg back pain zone. Further studies using the SP test supported by MATLAB are necessary to compare the SP test results with the clinical state and other types of nociplastic pain examination.
... e injection of corticosteroids, lidocaine, 5% dextrose water, hyaluronic acid (HA), or autologous platelet rich plasma (PRP) into the facet joints has been recommended to treat back pain or axial pain and leg pain or radicular pain induced by facet joint syndrome [2,3,[9][10][11][12][13][14][15]. However, needle insertion into the facet joints can be challenging due to spur development and degenerative changes [3,8,13,16]. ...
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Objective. This present study aimed to explore the clinical effects of ultrasound-guided (USG) mechanical needling with sterile water injection for lumbar facet joint syndrome. Methods. This was a retrospective cohort study that assessed the clinical outcome of ageing patients who received USG mechanical needling with sterile water injection. In addition, the clinical outcome of age- and gender-matched patients randomly selected from patients who received mechanical needling with sterile water was compared to the patients injected with steroids in a 2 : 1 ratio. The data were extracted from the medical records of ageing patients with facet joint syndrome who received USG injection at the lumbosacral spine by the first author. Low back pain or axial pain, and leg pain or radicular pain were assessed by the visual analogue scale (VAS), and gait ability with walking distance was obtained at 6 different time points. Results. A total of 4,276 medical records were examined. Four thousand two hundred twenty-eight ageing patients received needling with sterile water injection and found that the efficacy lasted up to 6 months. Ninety-six patients were compared with 48 patients who received steroid injection. Those who received steroids had less back and leg pain at 1 week after injection; however, pain returned at 3 months and 6 months after injection. Conclusions. USG mechanical needling with sterile water could help relieve axial and radicular pain for at least 6 months. Reduced sensitization and removal of calcification and fibrosis were all possible mechanisms.Keywords: Mechanical needling, Sterile water, Ultrasound guided (USG) injection, Facet joint syndrome, Pain
... 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. 30,32,33 While for some their pain characteristics appear clearly defi ned, LBP for many presents as a mixed picture refl ecting a combination of both peripheral and central pain mechanisms (see Fig. 45-1 ). 6 PLBP has also been associated with brain changes such as a loss of grey matter, increased resting brain state, changes in the sensorimotor cortex (i.e. ...
... e pain is felt by patients from the anatomical area of the back below the twelfth rib and above the inferior gluteal fold [3]. e symptoms can arise from many potential anatomic sources, such as nerve roots, muscles, fasciae, bones, joints, intervertebral discs (IVDs), and organs within the abdominal cavity [2,4,5]. e lumbar vertebrae are the main anatomical framework of the lower back. ...
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Introduction: Low back pain is the commonest musculoskeletal disorder affecting every socioeconomic group of the world's population. The lifetime risk of developing low back pain is about 60%-80%. The pooled prevalence and associated factors of low back pain have not yet been determined in Ethiopia. Thus, this study was aimed at assessing the overall prevalence of low back pain and its associated factors in Ethiopia. Methods: A systematic search of PubMed, Scopus, Science Direct, and Google Scholar for observational studies reporting data on the prevalence and associated factors of low back pain was conducted. Relevant data were extracted with a standardized data extraction excel form. Stata 14 was employed for the meta-analysis. Heterogeneity was assessed by Cochran's Q test and I 2 values of a forest plot. Publication bias was checked using a funnel plot and Egger's test. A random-effects model was used in the analysis. Result: A total of thirty-two studies were included for the systematic review. Twenty-four and sixteen studies were used to pool the overall low back pain prevalence and associated factors, respectively. The overall pooled annual prevalence of low back pain in Ethiopia was estimated to be 54.05% (95% CI: 48.14-59.96). Age, sex, body mass index, work experience, working hours, lack of safety training, awkward working posture, work shift, prolonged standing, lifting heavy objects, sleeping disturbance, history of back trauma, previous medical history of musculoskeletal disorder, and lack of adequate rest interval at work were significantly associated with low back pain. Conclusion: The current systematic review and meta-analysis revealed a higher prevalence of lower back pain in Ethiopia. Most of the low back pain epidemiological studies conducted in Ethiopia focused on specific occupational settings, making pooling of data and comparison with other countries challenging. Thus, further general population studies are recommended.
... Central sensitization has been described as a neurophysiological state related to amplified facilitator mechanisms and/or reduced inhibitory mechanisms [37]. The CSI does not directly assess central sensitization, but it is used as an indirect measurement tool to assess symptoms associated with central sensitization, such as fatigue, sleep and emotional disorders, and altered sensitivity to environmental stimuli, e.g., bright light and odors [34,38]. Thus, it points towards the potential existence of central sensitization and to the need to direct the intervention towards the central nervous system [39,40]. ...
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Background Neck pain tends to persist for periods of 1 to 4 years of follow-up in adolescents, and a high percentage of them report disability. However, studies assessing the factors associated with persistent neck pain and disability in this age group are scarce. This study aimed to explore the association between psychosocial factors, sleep, and symptoms of central sensitization at baseline and the persistence of neck pain and disability at 6-month follow-up.MethodsA total of 710 adolescents with chronic neck pain were assessed at baseline with an online questionnaire that collected information on sociodemographic data, presence of musculoskeletal pain, pain intensity, physical activity, functional disability, depression, anxiety, stress, quality of sleep, catastrophizing, kinesiophobia, self-efficacy, and symptoms of central sensitization. At 6-month follow-up, adolescents were reassessed for disability and pain intensity and categorized as recovered or reporting persistent neck pain.ResultsOf the 710 participants with neck pain at baseline, 334 were classified as having persistent neck pain and 375 adolescents as being recovered at 6-month follow-up. Multivariable analysis showed that female gender (OR 1.47; p = 0.04) and symptoms of central sensitization (OR 1.02; p = 0.001) at baseline were positively associated with the persistence of neck pain at 6-month follow-up. Similarly, higher levels of disability (β = 0.41; p < 0.001) and symptoms of central sensitization (β = 0.28; p < 0.001) at the baseline were positively associated with disability.Conclusions Symptoms of central sensitization and disability at baseline should be considered in the assessment and design of interventions for adolescents with chronic neck pain as an attempt to minimize its future impact on pain persistence and disability.
... We do not know how often that was reviewed or used are part of the prognostic process for this study. Specific examination questions or physical examination techniques that could be used to better screen for chronic pain may improve clinicians' accuracy in this regard (Smart et al., 2012). Our study did not use a prospective design to confirm development of chronic pain over time, but was limited to screening accuracy of risk for such chronicity during the first patient assessment compared to risk classification with the OMPQ. ...
Article
Introduction: Identifying patients at risk for chronic musculoskeletal pain can inform evaluation and treatment decisions. The ability of physical therapists to assess patients’ risk for chronic pain without use of validated tools has been questioned. The Ӧrebro Musculoskeletal Pain Questionnaire (OMPQ) is used to determine risk for chronic pain. Methods: The aim of this pragmatic study was to prospectively quantify the agreement between physical therapists’ assessment of patients’ risk for chronic symptoms compared to the OMPQ. Patients were asked to complete the OMPQ during the initial visit. Physical therapists, blinded to OMPQ risk classification, carried out their usual patient assessment procedures. The physical therapists rated patients as either high or low risk for chronic pain based on their clinical assessment. Agreement between therapist and OMPQ was determined using Cohen’s Kappa (κ) and screening accuracy compared clinician risk to the OMPQ risk classification (reference standard) by way of contingency table analysis. Results: Ninety-six (96) patients’ risk classifications and 15 corresponding physical therapists’ risk estimates were available for analysis. The OMPQ identified a 47% prevalence for high risk of chronic pain. Agreement (κ and 95% confidence interval) between physical therapist rating and OMPQ was slight, κ = 0.272 (0.033–0.421), p = .026. Therapists’ sensitivity and specificity (95% CI) for determining risk classifications were 60.0% (44.3–74.3) and 62.8% (48.1–75.6), respectively. The positive and negative likelihood ratios (95% CI) were 1.61 (1.05–2.47) and 0.64 (0.42–0.97). Discussion: The use of validated self-report questionnaires are recommended to supplement clinician prognosis for patients at risk of chronic musculoskeletal pain.
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Chronic Pain is a distressing experience with sensory, emotional, social and cognitive components and affects millions of people globally with a huge impact on the economy.Pain has traditionally been classified as nociceptive (from tissue injury) and neuropathic (from nerve injury) but more recently a third mechanistic descriptor has been identified and defined as nociplastic pain (from a sensitised nervous system). Nociplastic pain, therefore, is stimulus-independent and does not require inflammation or structural neuronal damage. Central sensitisation is one of the mechanisms that explain chronic persistent pain and represents an enhancement in the function of neurons and circuits in pain pathways and is a manifestation of the remarkable plasticity of the nervous system in response to soft tissue injury, inflammation, and neural injury. Patients presenting with symptoms of central sensitisation typically show higher pain ratings, and greater disability, are more likely to develop future musculoskeletal conditions and show poorer outcomes and increased likelihood of developing chronic persistent pain.
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Bladder pain syndrome (BPS) is a debilitating condition characterised by exaggerated bladder sensations and altered bladder function. It is still unknown whether the condition is a peripheral sensory problem or due to abnormal central sensory processing as seen in central sensitisation. This systematic review, which followed a published and Prospective Register of Systematic Reviews-registered protocol (CRD42021229962), is aimed at establishing the scope of central sensitisation in patients with BPS to aid optimal management and treatment. Four databases were searched, and appraisal of the identified studies was conducted by two independent reviewers based on eligibility criteria: patients with BPS being investigated for central sensitisation with or without comparison of controls, English-language articles, full text and publication in a peer-reviewed journal. The Methodological Index for non-Randomised Studies was used to determine study quality. We identified 763 papers in total, with 15 studies included in the final analysis. All studies were observational and had a low risk of bias. Measures included in the evaluation of CS were questionnaires, urodynamics, and quantitative sensory testing methods. There was evidence of central sensitisation in patients with BPS in all papers evaluated (15 out of 15). In addition, more significant central sensitisation correlated with severe disease presentation (3 out of 3 papers) and concomitant chronic pain conditions (5 out of 5 papers). Central sensitisation plays an integral role in BPS patient pathology. Many secondary measures are used to evaluate this condition. Stratification of patients based on their pathology (peripheral, central or a combination of the two) will aid in implementing an individualised management strategy.
Article
Background and purpose: Nociplastic pain due to central sensitization (CS) is common in people suffering from chronic pain, but no clinical practice guideline is available in rehabilitative settings for patients' management. The aim of this study is to achieve expert consensus on physiotherapy competencies in the management of people with nociplastic pain and suspected CS mechanisms. Methods: A web-based Delphi process was employed. Experts in the rehabilitation field were recruited following pre-defined eligibility criteria. Following completion of three Delphi rounds, the final list of competencies was generated. Results: In all, 23 participants were recruited. They all completed Round 1 (23/23, 100%), twenty Round 2 and Round 3 (20/23, 87%). Following Round 1, seven areas were identified by the panel as crucial for CS physiotherapy management; 19 competencies out of 40 reached the consensus between experts, and nine additional competencies were added to Round 2 following literary review. Round 2 identified the agreement for all the 29 competencies. During Round 3, all the experts confirmed the final list generated through the consensus process. Discussion: An agreement between experts was found for the final list of competencies that a physiotherapist should implement every time it approaches people with suspected CS mechanisms. Further research is needed to support the clinical utility of our findings and their applicability in daily practice.
Article
Context Central sensitization (CS) has been proposed as a common underlying pathophysiology to explain poorly understood pain-related syndromes. This is termed under central sensitivity syndromes (CSSs), for which no specific organic cause has been found. Aims The aim of the present study was to investigate whether there is an association between the CS Inventory (CSI) score, pain-related symptoms, pain-related disability, health-related quality of life (QOL), and poorly understood pain-related syndromes and whether they differed by disease type. This study also evaluated the association between severity of CS and the associated CSSs. Methods A total of seventy patients who attended a pain clinic (chronic pain outpatient department) were assessed randomly. CSI score, CSSs, EuroQOL-5 Dimension-5 Level, Brief Pain Inventory, and Fibromyalgia (FM) Severity Scale were assessed and compared. Statistical Analysis Univariate correlation analysis was performed in each group to evaluate: (1) severity of CS, (2) presence/absence of CSSs, (3) pain intensity and pain interference, and (4) CSI score and FM Severity Scale. Results CSI score has a significant association with CSSs, pain-related symptoms such as pain/discomfort, anxiety/depression, mood, and sleep. Conclusions In our study, CS has been shown to have a significant impact on mean pain score and QOL by strongly impacting mobility, mood, and sleep. CS is the underlying root cause of various CSSs. This study concludes that CS should be evaluated as a routine in all chronic pain patients.
Article
Post-traumatic stress disorder (PTSD) and chronic low back pain (CLBP) are frequently co-morbid. Some research suggests that PTSD and CLBP may share common neurobiological mechanisms related to stress. Traditional biomedical education may be ineffective for PTSD and CLBP, especially when co-morbid. The purpose of this study is to determine if pain neuroscience education (PNE) is more effective than traditional education in reducing PTSD, disability, pain, and maladaptive beliefs in patients with CLBP. Participants with CLBP and possible PTSD/PTSD-symptoms were recruited for this study. Participants were randomly allocated to a PNE group or a traditional education group. The intervention included 30 minutes of education followed by a standardized exercise program once a week for 4-weeks with a 4 and 8-week follow-up and healthcare utilization assessed at 12-months. Forty-eight participants consented for this research study with 39 allocated to treatment (PNE n = 18, traditional n = 21). PNE participants were more likely to achieve a clinically meaningful reduction in PTSD symptoms and disability at short-term follow-up. At 12-months, the PNE group utilized healthcare with 76% lower costs. In participants with CLBP, PNE may reduce hypervigilance toward pain and improve PTSD symptoms. Participants who received PNE were more confident body-tissues were safe to exercise. These beliefs about pain could contribute to a decrease in perceived disability and healthcare consumption for CLBP.
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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
Article
Introduction Symptomatic lumbar disc herniations have a prevalence of 1-3% in the general population. Clinical examination is utilized to identify the level of nerve root impingement using pain or sensory changes in dermatomal patterns. These findings are often cited as beneficial for pre-operative planning to localize the level of nerve root impingement in conjunction with advanced imaging. Recent studies have challenged the accuracy of previous dermatomal distributions. Objective To evaluate the rate of correlation for altered sensation and pain in dermatomal distributions with the specific level of nerve root compression. Methods A systematic review was performed using PRISMA guidelines. A search was performed on PUBMED/MEDLINE, Cochrane Database and Embase on 08 OCT 2022. Search keywords were “nerve root, disc herniation, physical examination, lumbar”. CT, MRI or intra-operative findings for level of nerve root compression were recorded. Dermatomal pain or sensation on physical examination were compared to the level of nerve root compression. Results A total of three hundred and forty-seven articles were obtained from the literature search. Eighty-one full length articles were obtained and reviewed. Full data was obtained from seven articles. Overall correlation of physical examination findings with nerve root compression ranged from 5-93%. Overall correlation was 42%. L4 correlation ranged from 7.7-33%. L5 compression correlated 7.1-41%. S1 physical examination matched 2.4-54%. Conclusion Dermatomal pain and sensory loss are utilized for identifying nerve root compression. The current systematic review identified an overall correlation of 42% with physical examination for sensory loss and the level of lumbar nerve root compression.
Article
Background: Early evidence suggests human assumed central sensitisation (HACS) is present in some people with acute low back pain (LBP). Factors influencing individual variation in HACS during acute LBP have not been fully explored. We aimed to examine the evidence for HACS in acute LBP and the contribution of brain-derived neurotrophic factor (BDNF), clinical, psychological and demographic factors to HACS. Methods: Participants with acute LBP (<6 weeks after pain onset, N=118) and pain-free controls (N=57) from a longitudinal trial were included. Quantitative sensory testing including pressure and heat pain thresholds and conditioned pain modulation, BDNF serum concentration and genotype and questionnaires were assessed. Results: There were no signs of HACS during acute LBP at group level when compared with controls. Sensory measures did not differ when compared between controls and LBP participants with different BDNF genotypes. Two LBP subgroups with distinct sensory profiles were identified. Although one subgroup (N=60) demonstrated features of HACS including pressure/heat pain hypersensitivity at a remote site and deficient conditioned pain modulation, pain severity and disability did not differ between the two subgroups. Variation in sensory measures (~33%) was partially explained by BDNF genotype, sex, age and psychological factors. Conclusions: This study confirms that HACS is present in some people with acute LBP, but this was not associated with pain or disability. Further, no relationship was observed between BDNF and HACS in acute LBP. More research is needed to understand factors contributing to individual variation in sensory measures in LBP.
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Ist eine Rehabilitation nach einer Bandscheibenoperation notwendig? Und wenn ja, wie sollte diese gestaltet werden? Christoph Thalhamer diskutiert die Frage nach der Notwendigkeit und stellt anhand aktueller Literatur ein Best-Practice-Modell der postoperativen Rehabilitation vor.
Article
Introduction: Exercise is the most recommended treatment for chronic low back pain (CLBP) and is effective in reducing pain, but the mechanisms underlying its effects remain poorly understood. Exercise-induced hypoalgesia (EIH) may play a role and is thought to be driven by central pain modulation mechanisms. However, EIH appears to be disrupted in many chronic pain conditions and its presence in people with CLBP remains unclear. As people suffering from chronic pain often exhibit psychological factors and central sensitization symptoms influencing pain perception, EIH might be associated to these factors. Objective: To compare the level of EIH between participants with and without CLBP following back and wrist exercises and to assess the associations between EIH, psychological factors and central sensitization inventory score (CSI) in CLBP. Method: Twenty-eight participants with CLBP and 23 without pain were recruited. Pressure pain thresholds (PPT) were measured at 4 sites (2 bony sites = capitate, S1 | 2 muscle sites = wrist flexors, lumbar erector spinae) before and after each of two exercises (wrist flexion and lumbar extension). EIH was defined as percent change in PPT from pre-to-post-exercise. Participants with CLBP also completed questionnaires to measure psychological factors (e.g. kinesiophobia, catastrophizing, anxiety, self-efficacy) and symptoms of central sensitization (CSI), and correlations with EIH was calculated. Results: After wrist exercise, EIH measured at the muscle sites was lower in the CLBP group compared to the pain-free group (p=0.047) but no differences were found at bony sites (p=0.49). No significant differences for EIH were observed following back exercise at muscle sites (p=0.14) or at bony sites (p=0.65). EIH was not correlated with any psychological factors or to the CSI score. Conclusion: The lower EIH following wrist exercises may represent an alteration in pain modulation control in CLBP. However, psychological factors and central sensitization symptoms may not explain the differences observed.
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Background: Chronic low back pain (CLBP) is a debilitating condition that persists despite the lack of tissue damage and an effective management is still lacking. CLBP is a multifactorial disorder comprising psychosocial factors like pain catastrophization, fear avoidance and central sensitization. Objectives: to investigate the effect of Cognitive Behavioural Therapy on CLBP patients with Central sensitization. Methods: This randomized clinical study was conducted on thirty patients of both genders having chronic low back pain with central sensitization, their age ranged from 20-37years old. The 30 patients were divided into two groups. The first group received Cognitive Behavioural Therapy comprising of one session neurophysiology education, one biofeedback relaxation session and three sessions comprising functional training exercises. The second group received conventional physiotherapy treatment comprising 12 sessions of TENS and core strengthening exercises over the course of 4 weeks. Results: The results of this study showed a significant improvement in pain intensity according to the NPRS of 30.02% in the CBT group while only 5.82% in the conventional physiotherapy group. Conclusion: Cognitive Behavioural Therapy has a significant effect on chronic low back pain, disability and fear avoidance behavior related to its central sensitivity aspects which are neglected by conventional treatment physiotherapy. Larger studies are required to establish the best feasible treatment protocol.
Article
Background: The use of pain neuroscience education (PNE) in the management of chronic musculoskeletal pain is well documented in the literature for the adult population. However, the use of this component within the larger biopsychosocial approach has not been examined in adults with intellectual disabilities. The purpose of this case report is to describe the utilization of a PNE approach combined with exercise in the physical therapy management of chronic musculoskeletal pain in an adult with Down syndrome. Case description: The patient was a 40-year-old man with Down syndrome who presented with chronic low back pain that affected his sleep, participation at work, and social activities. Modified metaphors were used to assist the patient in understanding his pain experience as part of a multi-modal program that included exercise and aquatic therapy. Outcomes: Upon concluding 11 weeks of treatment, the patient returned to his prior work schedule and social activities with a pain rating at worst of 3/10 on the numeric pain rating scale with only occasional pain episodes. His disability score on the Oswestry Disability Index improved by 39% relative to baseline. Discussion: The findings demonstrate how utilizing PNE within a physical therapy plan of care was used in the management of chronic musculoskeletal pain to improve function in an adult with Down syndrome.
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Introduction: Central pain facilitation can hinder recovery in people with chronic low back pain (CLBP). Objectives: The objective of this observational study was to investigate whether indices of centrally facilitated pain are associated with pain outcomes in a hospital-based cohort of individuals with CLBP undertaking a pain management programme. Methods: Participants provided self-report and pain sensitivity data at baseline (n = 97) and again 3 months (n = 87) after a cognitive behavioural therapy-based group intervention including physiotherapy. Indices of centrally facilitated pain were pressure pain detection threshold, temporal summation and conditioned pain modulation at the forearm, Widespread Pain Index (WPI) classified using a body manikin, and a Central Mechanisms Trait (CMT) factor derived from 8 self-reported characteristics of anxiety, depression, neuropathic pain, fatigue, cognitive dysfunction, pain distribution, catastrophizing, and sleep. Pain severity was a composite factor derived from Numerical Rating Scales. Cross-sectional and longitudinal regression models were adjusted for age and sex. Results: Baseline CMT and WPI each was associated with higher pain severity (CMT: r = 0.50, P < 0.001; WPI: r = 0.21, P = 0.04) at baseline and at 3 months (CMT: r = 0.38, P < 0.001; WPI: r = 0.24, P = 0.02). High baseline CMT remained significantly associated with pain at 3 months after additional adjustment for baseline pain (β = 2.45, P = 0.04, R 2 = 0.25, P < 0.0001). Quantitative sensory testing indices of pain hypersensitivity were not significantly associated with pain outcomes at baseline or at 3 months. Conclusion: Central mechanisms beyond those captured by quantitative sensory testing are associated with poor CLBP outcome and might be targets for improved therapy.
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CLINICAL SCENARIO You are back where we put you in the previous article1 on diagnostic tests in this series on how to use the medical literature: in the library studying an article that will guide you in interpreting ventilation-perfusion (V/Q) lung scans. Using the criteria in Table 1, you have decided that the Prospective Investigation of Pulmonary Diagnosis (PIOPED) study2 will provide you with valid information. Just then, another physician comes looking for an article to help with the interpretation of V/Q scanning. Her patient is a 28-year-old man whose acute onset of shortness of breath and vague chest pain began shortly after completing a 10-hour auto trip. He experienced several episodes of similar discomfort in the past, but none this severe, and is very apprehensive about his symptoms. After a normal physical examination, electrocardiogram and chest radiograph, and blood gas measurements that show a Pco2 of
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Introduction to the Logistic Regression Model Multiple Logistic Regression Interpretation of the Fitted Logistic Regression Model Model-Building Strategies and Methods for Logistic Regression Assessing the Fit of the Model Application of Logistic Regression with Different Sampling Models Logistic Regression for Matched Case-Control Studies Special Topics References Index.
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The purpose of this article is to review the case for the inclusion of a mechanisms-based classification for musculoskeletal pain. In response to perceived limitations of the medical/disease model of pain and illness a mechanisms-based classification system for pain has been advocated. The classification of pain according to the underlying neurophysiological mechanisms responsible for its generation and/or maintenance may better explain the variability and complexities of clinical presentations of musculoskeletal pain and facilitate subsequent decision-making associated with the assessment, treatment and prognosis of patients with musculoskeletal disorders. However, current methods of mechanisms-based classification either lack standardised criteria or propose decision rules whose validity has yet to be substantiated empirically. While the case for a mechanisms-based classification for pain has been well made the onus rests with its advocates to (a) establish its validity for use in clinical practice in defined populations with musculoskeletal disorders, and (b) provide evidence that such a system facilitates improved clinical outcomes.
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The classification of low back pain has been proposed as a high research priority due to the possible confounding effect of sample heterogeneity on effect sizes for outcome studies investigating treatment efficacy. However, the literature is unclear regarding methodological criteria for the development and validation of low back pain classification systems. The objectives of this paper were to describe and discuss the methodology used in studies researching the development and validation of low back pain classification systems. A database search for relevant papers was conducted, and data describing the frequency of utilisation of specific methodologies extracted and summarised. Seventy-seven papers were included in the review. Considerable variability in the methodological approaches used was found. Based on the results of the review and a comparison with the theory of classification, recommendations are made for future research into the classification of low back pain.
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Empirical evidence of discriminative validity is required to justify the use of mechanisms-based classifications of musculoskeletal pain in clinical practice. The purpose of this study was to evaluate the discriminative validity of mechanisms-based classifications of pain by identifying discriminatory clusters of clinical criteria predictive of "nociceptive," "peripheral neuropathic," and "central sensitization" pain in patients with low back (± leg) pain disorders. This study was a cross-sectional, between-patients design using the extreme-groups method. Four hundred sixty-four patients with low back (± leg) pain were assessed using a standardized assessment protocol. After each assessment, patients' pain was assigned a mechanisms-based classification. Clinicians then completed a clinical criteria checklist indicating the presence/absence of various clinical criteria. Multivariate analyses using binary logistic regression with Bayesian model averaging identified a discriminative cluster of 7, 3, and 4 symptoms and signs predictive of a dominance of "nociceptive," "peripheral neuropathic," and "central sensitization" pain, respectively. Each cluster was found to have high levels of classification accuracy (sensitivity, specificity, positive/negative predictive values, positive/negative likelihood ratios). By identifying a discriminatory cluster of symptoms and signs predictive of "nociceptive," "peripheral neuropathic," and "central" pain, this study provides some preliminary discriminative validity evidence for mechanisms-based classifications of musculoskeletal pain. Classification system validation requires the accumulation of validity evidence before their use in clinical practice can be recommended. Further studies are required to evaluate the construct and criterion validity of mechanisms-based classifications of musculoskeletal pain.
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Chronic whiplash is a debilitating condition characterized by increased sensitivity to painful stimuli, maladaptive illness beliefs, inappropriate attitudes, and movement dysfunctions. Previous work in people with chronic low back pain and chronic fatigue syndrome indicates that pain neurophysiology education is able to improve illness beliefs and attitudes as well as movement performance. This single-case study (A-B-C design) with six patients with chronic whiplash associated disorders (WAD) was aimed at examining whether education about the neurophysiology of pain is accompanied by changes in symptoms, daily functioning, pain beliefs, and behavior. Periods A and C represented assessment periods, while period B consisted of the intervention (pain neurophysiology education). Results showed a significant decrease in kinesiophobia (Tampa Scale for Kinesiophobia), the passive coping strategy of resting (Pain Coping Inventory), self-rated disability (Neck Disability Index), and photophobia (WAD Symptom List). At the same time, significantly increased pain pressure thresholds and improved pain-free movement performance (visual analog scale on Neck Extension Test and Brachial Plexus Provocation Test) were established. Although the current results need to be verified in a randomized, controlled trial, they suggest that education about the physiology of pain is able to increase pain thresholds and improve pain behavior and pain-free movement performance in patients with chronic WAD.
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Nociceptor inputs can trigger a prolonged but reversible increase in the excitability and synaptic efficacy of neurons in central nociceptive pathways, the phenomenon of central sensitization. Central sensitization manifests as pain hypersensitivity, particularly dynamic tactile allodynia, secondary punctate or pressure hyperalgesia, aftersensations, and enhanced temporal summation. It can be readily and rapidly elicited in human volunteers by diverse experimental noxious conditioning stimuli to skin, muscles or viscera, and in addition to producing pain hypersensitivity, results in secondary changes in brain activity that can be detected by electrophysiological or imaging techniques. Studies in clinical cohorts reveal changes in pain sensitivity that have been interpreted as revealing an important contribution of central sensitization to the pain phenotype in patients with fibromyalgia, osteoarthritis, musculoskeletal disorders with generalized pain hypersensitivity, headache, temporomandibular joint disorders, dental pain, neuropathic pain, visceral pain hypersensitivity disorders and post-surgical pain. The comorbidity of those pain hypersensitivity syndromes that present in the absence of inflammation or a neural lesion, their similar pattern of clinical presentation and response to centrally acting analgesics, may reflect a commonality of central sensitization to their pathophysiology. An important question that still needs to be determined is whether there are individuals with a higher inherited propensity for developing central sensitization than others, and if so, whether this conveys an increased risk in both developing conditions with pain hypersensitivity, and their chronification. Diagnostic criteria to establish the presence of central sensitization in patients will greatly assist the phenotyping of patients for choosing treatments that produce analgesia by normalizing hyperexcitable central neural activity. We have certainly come a long way since the first discovery of activity-dependent synaptic plasticity in the spinal cord and the revelation that it occurs and produces pain hypersensitivity in patients. Nevertheless, discovering the genetic and environmental contributors to and objective biomarkers of central sensitization will be highly beneficial, as will additional treatment options to prevent or reduce this prevalent and promiscuous form of pain plasticity.
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Central sensitization plays an important role in the pathophysiology of numerous musculoskeletal pain disorders, yet it remains unclear how manual therapists can recognize this condition. Therefore, mechanism based clinical guidelines for the recognition of central sensitization in patients with musculoskeletal pain are provided. By using our current understanding of central sensitization during the clinical assessment of patients with musculoskeletal pain, manual therapists can apply the science of nociceptive and pain processing neurophysiology to the practice of manual therapy. The diagnosis/assessment of central sensitization in individual patients with musculoskeletal pain is not straightforward, however manual therapists can use information obtained from the medical diagnosis, combined with the medical history of the patient, as well as the clinical examination and the analysis of the treatment response in order to recognize central sensitization. The clinical examination used to recognize central sensitization entails the distinction between primary and secondary hyperalgesia.
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Unlabelled: Central sensitization represents an enhancement in the function of neurons and circuits in nociceptive pathways caused by increases in membrane excitability and synaptic efficacy as well as to reduced inhibition and is a manifestation of the remarkable plasticity of the somatosensory nervous system in response to activity, inflammation, and neural injury. The net effect of central sensitization is to recruit previously subthreshold synaptic inputs to nociceptive neurons, generating an increased or augmented action potential output: a state of facilitation, potentiation, augmentation, or amplification. Central sensitization is responsible for many of the temporal, spatial, and threshold changes in pain sensibility in acute and chronic clinical pain settings and exemplifies the fundamental contribution of the central nervous system to the generation of pain hypersensitivity. Because central sensitization results from changes in the properties of neurons in the central nervous system, the pain is no longer coupled, as acute nociceptive pain is, to the presence, intensity, or duration of noxious peripheral stimuli. Instead, central sensitization produces pain hypersensitivity by changing the sensory response elicited by normal inputs, including those that usually evoke innocuous sensations. Perspective: In this article, we review the major triggers that initiate and maintain central sensitization in healthy individuals in response to nociceptor input and in patients with inflammatory and neuropathic pain, emphasizing the fundamental contribution and multiple mechanisms of synaptic plasticity caused by changes in the density, nature, and properties of ionotropic and metabotropic glutamate receptors.
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In epidemiological studies researchers use logistic regression as an analytical tool to study the association of a binary outcome to a set of possible exposures. Using a simulation study we illustrate how the analytically derived bias of odds ratios modelling in logistic regression varies as a function of the sample size. Logistic regression overestimates odds ratios in studies with small to moderate samples size. The small sample size induced bias is a systematic one, bias away from null. Regression coefficient estimates shifts away from zero, odds ratios from one. If several small studies are pooled without consideration of the bias introduced by the inherent mathematical properties of the logistic regression model, researchers may be mislead to erroneous interpretation of the results.
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Emotional-affective and cognitive dimensions of pain are less well understood than nociceptive and nocifensive components, but the forebrain is believed to play an important role. Recent evidence suggests that subcortical and cortical brain areas outside the traditional pain processing network contribute critically to emotional-affective responses and cognitive deficits related to pain. These brain areas include different nuclei of the amygdala and certain prefrontal cortical areas. Their roles in various aspects of pain will be discussed. Biomarkers of cortical dysfunction are being identified that may evolve into therapeutic targets to modulate pain experience and improve pain-related cognitive impairment. Supporting data from preclinical studies in neuropathic pain models will be presented. Neuroimaging analysis provides evidence for plastic changes in the pain processing brain network. Results of clinical studies in neuropathic pain patients suggest that neuroimaging may help determine mechanisms of altered brain functions in pain as well as monitor the effects of pharmacologic interventions to optimize treatment in individual patients. Recent progress in the analysis of higher brain functions emphasizes the concept of pain as a multidimensional experience and the need for integrative approaches to determine the full spectrum of harmful or protective neurobiological changes in pain.
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This study describes the development and validation of a novel tool for identifying patients in whom neuropathic mechanisms dominate their pain experience. The Leeds assessment of neuropathic symptoms and signs (LANSS) Pain Scale is based on analysis of sensory description and bedside examination of sensory dysfunction, and provides immediate information in clinical settings. It was developed in two populations of chronic pain patients. In the first (n = 60), the use of sensory descriptors and questions were compared in patients with nociceptive and neuropathic pain, combined with an assessment of sensory function. This data was used to derive a seven item pain scale, consisting of grouped sensory description and sensory examination with a simple scoring system. The LANSS Pain Scale was validated in a second group of patients (n = 40) by assessing discriminant ability, internal consistency and agreement by independent raters. Clinical and research applications of the LANSS Pain Scale are discussed.
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Clinicians and those in health sciences are frequently called upon to measure subjective states such as attitudes, feelings, quality of life, educational achievement and aptitude, and learning style in their patients. This fifth edition of Health Measurement Scales enables these groups to both develop scales to measure non-tangible health outcomes, and better evaluate and differentiate between existing tools. Health Measurement Scales is the ultimate guide to developing and validating measurement scales that are to be used in the health sciences. The book covers how the individual items are developed; various biases that can affect responses (e.g. social desirability, yea-saying, framing); various response options; how to select the best items in the set; how to combine them into a scale; and finally how to determine the reliability and validity of the scale. It concludes with a discussion of ethical issues that may be encountered, and guidelines for reporting the results of the scale development process. Appendices include a comprehensive guide to finding existing scales, and a brief introduction to exploratory and confirmatory factor analysis, making this book a must-read for any practitioner dealing with this kind of data.
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Plasticity enables alterations in transmission in nociceptive systems. It is this plasticity in the nervous system that can alter the linear relation between noxious stimuli and the perception of pain. In this way, a number of central nervous system mechanisms can alter neuronal activity, leading to abnormal and stimulus-evoked pains due to peripheral and central changes. Peripheral nerves can become sensitized, spinal cord neurons can be rendered hyperexcitable and ascending projections to higher centres can further trigger changes in descending controls from the midbrain and brainstem. Together, these changes, all of which appear to involve reversible physiological and pharmacological plasticity, can alter the relationship between an applied stimulus and the perceived response and so lead to persistent pain states. This article considers these signalling systems and changes in the context of chronic pain.
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Plasticity enables alterations in transmission in nociceptive systems. It is this plasticity in the nervous system that underlies the adaptive, non-dependable relationship between the intensity of noxious stimuli and the perception of pain. In this way, a number of CNS mechanisms can alter neuronal activity, leading to abnormal ongoing and stimulus-evoked pains. Peripheral nerves can become sensitized, spinal cord neurons can be rendered hyperexcitable and ascending projections to higher centres can further trigger changes in descending controls from the midbrain and brainstem. Together, these changes, all of which appear to involve reversible physiological and pharmacological plasticity, can alter the relationship between an applied stimulus and the perceived response and so lead to persistent pain states. Clinically important pains are now known to have distinct neurophysiological and pharmacological substrates that underlie the transmission of impulses from the periphery to the CNS as compared with the mechanisms that underlie the sensations evoked by acute noxious stimuli. This plasticity, the ability of the nervous system to alter in response to injury-evoked dysfunction leads to changes that can be observed throughout the pathways involved in the perception of pain.
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