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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... Although exercise typically induces hypoalgesia by activating descending inhibitory pain mechanisms, this is not always the case in individuals with central sensitization. 58 In fact, the opposite can happen, and exercise that is too aggressive can trigger sensitized peripheral nociceptors and cause significant increases in pain for prolonged periods of time. 58 A key concept in prescribing exercise with this patient group is to appropriately match patient symptom levels and symptom irritability with exercise intensity. ...
... 58 In fact, the opposite can happen, and exercise that is too aggressive can trigger sensitized peripheral nociceptors and cause significant increases in pain for prolonged periods of time. 58 A key concept in prescribing exercise with this patient group is to appropriately match patient symptom levels and symptom irritability with exercise intensity. In the centrally sensitized patient, lower exercise intensities are capable of inducing exercise hypoalgesia, which in turn will reinforce exercise performance. ...
... 63 Strengthening exercise, as discussed in a previous section, has been demonstrated to produce pain-relieving effects. 8,58 In addition, exercise can improve function, thereby decreasing disability, and can help prevent development of chronic pain. 58 Even with multiple known benefits of exercise, research on specifics of load, intensity, duration, total volume of activity, and variation based on tissue type is only beginning to emerge regarding specific exercise prescription. ...
... 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
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Persistence of low back pain is thought to be associated with different underlying pain mechanisms, including ongoing nociceptive input and central sensitisation. We hypothesised that primary motor cortex (M1) representations of back muscles (a measure of motor system adaptation) would differ between pain mechanisms, with more consistent observations in individuals presumed to have an ongoing contribution of nociceptive input consistently related to movement/posture. We tested 28 participants with low back pain sub‐grouped by the presumed underlying pain mechanisms: nociceptive pain, nociplastic pain, and a mixed group with features consistent with both. Transcranial magnetic stimulation was used to study M1 organization of back muscles. M1 maps of multifidus (deep & superficial), and longissimus erector spinae were recorded with fine‐wire electromyography and thoracic erector spinae with surface electromyography. The nociplastic pain group had greater variability in M1 map location (centre of gravity) than other groups (p<0.01), which may suggest less consistency, and perhaps relevance, of motor cortex adaptation for that group. The mixed group had greater overlap of M1 representations between deep/superficial muscles than nociceptive pain (deep multifidus/longissimus: p=0.001, deep multifidus/thoracic erector spinae: p=0.008), and nociplastic pain (deep multifidus/longissimus: p=0.02, deep multifidus/thoracic erector spinae: p= 0.02) groups. This study provides preliminary evidence of differences in M1 organisation in subgroups of low back pain classified by likely underlying pain mechanisms. Despite the sample size, differences in cortical re‐organisation between subgroups were detected. Differences in M1 organisation in subgroups of low back pain supports tailoring of treatment based on pain mechanism and motor adaptation.
... The neck and shoulder pain, which at worst reached a 9/10 on an NPRS scale, had improved minimally over the last 6 weeks and varied in intensity, with a lowest reported pain level of 6/10 and an average pain level of 7/10. According to Smart et al [24], disproportional pain ratings have been implicated in states of CS. The patient reported aggravating factors for her neck and shoulder, included standing, walking for extended periods, transferring from sit to stand, turning the neck while operating a motor vehicle, and reaching overhead to high shelves. ...
... The patient subjectively reported her pain often limited her from activities, and she was afraid to aggravate her condition with physical activity, indicating fear avoidance beliefs. Fear avoidance has been implicated in states of CS [24]. The patient also reported a history of low back and left hip pain starting in 1982, as well as left lateral foot pain. ...
... The patient presented with subjective reports that indicated fear avoidance, and a disproportional pain rating both described in the literature as related to CS and persistent pain [24]. The objective tests and measures showed positive test results with neural tissue tension techniques, indicating peripheral neuropathic pain as well [26]. ...
Article
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BACKGROUND Persistent pain is one of the most common reasons individuals seek healthcare in the United States, costing $635 billion annually. At present, the medical literature outlines many treatments for persistent pain. Pain neuroscience education (PNE) is described in the literature as an educational intervention for patients with persistent pain that can be applied by a physical therapist. There is limited research on the application of PNE by a student physical therapist; however, this case report offers a unique opportunity to examine outcomes for this intervention when applied by a student physical therapist in conjunction with manual therapy and therapeutic exercise. CASE REPORT This case report examined the outcomes of PNE for a 65-year-old patient with a long-standing history of low back, cervical, shoulder, knee, and foot pain. Interventions included 7 sessions of PNE over 4 weeks delivered by a student physical therapist, in combination with manual therapy and exercise prescribed by a licensed physical therapist. Outcomes measured were fear avoidance belief questionnaire, visual analog scale, Tampa scale of kinesiophobia, neurophysiology of pain questionnaire, neck disability index, and Oswestry disability index. CONCLUSIONS Outcomes included clinically significant decreases in subjective pain level, and kinesiophobia; however, there was only a minimal decrease in fear avoidance and no decrease in perceived disability. This case report provides preliminary evidence that positive outcomes can be achieved when PNE is delivered by a student physical therapist combined with manual therapy and therapeutic exercise from an expert clinician for patients with persistent musculoskeletal pain.
... The use of questionnaires is feasible as they involve self-administered questions and/or simple clinical tests. Three multicomponent systems designed to discriminate between pain mechanisms (Smart,194,(196)(197)(198)175,178 and Kolski 102 classifications) and 3 sets of criteria (Berlin criteria for inflammatory pain, 99,169 RAPIDH criteria for radicular pain [a type of peripheral neuropathic pain], 73 and NeuPSIG neuropathic pain grading system 64,213,220 ) have been tested for validity regarding discrimination between PMCs. Classification systems performed well in most criteria. ...
... Some systems have been developed to discriminate between the 3 main PMCs, their subtypes, or just identify a single PMC. Systems developed by Smart et al. [196][197][198][199] and Nijs et al. 141,144 aim to discriminate between nociceptive, neuropathic, and nociplastic (central sensitisation) pain, whereas the system devised by Schafer et al. 178 aims to discriminate between 3 subgroups of neuropathic pain (denervation, peripheral nerve sensitisation, and neuropathic sensitisation) and nociceptive pain (referred to as musculoskeletal pain). The NeuPSIG neuropathic grading system has been used to identify neuropathic pain. ...
... There is some divergence of opinion regarding the number of categories, terminology, and/or definitions for PMCs and the criteria to discriminate between PMCs ( Table 9). For instance, Smart et al. [196][197][198] described discrimination between 3 PMCs (nociceptive, peripheral neuropathic, central sensitisation pain) and based criteria and validation on a clinical opinion of musculoskeletal physiotherapists. Nijs et al. 141,144 refer to "neuropathic pain" identified by the NeuSPIG criteria (eg, evidence of neural damage) and focus on subjective pain examination and history as evidence of a reasonable explanation for nociceptive pain. ...
Article
Mechanism-based classification of pain has been advocated widely to aid tailoring of interventions for individuals experiencing persistent musculoskeletal pain. Three pain mechanism categories are defined by the International Association for the Study of Pain: nociceptive, neuropathic, and nociplastic pain. Discrimination between them remains challenging. This study aimed to: build on a framework developed to converge the diverse literature of pain mechanism categories to systematically review methods purported to discriminate between them; synthesise and thematically analyse these methods to identify convergence and divergence of opinion; and report validation, psychometric properties and strengths/weaknesses of these methods. The search strategy identified papers discussing methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system. Studies that assessed validity of methods to discriminate between categories were assessed for quality. Extraction and thematic analysis were undertaken on 184 papers. Data synthesis identified 200 methods in five themes: clinical examination, quantitative sensory testing, imaging, diagnostic and laboratory testing, and pain-type questionnaires. Few methods have been validated for discrimination between pain mechanism categories. There was general convergence but some disagreement regarding findings that discriminate between pain mechanism categories. A combination of features and methods, rather than a single method, was generally recommended to discriminate between pain mechanism categories. Two major limitations were identified: overlap of findings of methods between categories due to mixed presentations, and many methods considered discrimination between two pain mechanism categories but not others. The results of this review provide a foundation to refine methods to differentiate mechanisms for musculoskeletal pain.
... They then used statistical modeling based on patient symptoms to identify predominant sources of a patient's symptoms who have LBP. Through this approach, they identified a mechanisms-based classification for musculoskeletal pain that included: 1) central sensitization; 34 2) peripheral neuropathic (radicular or referred), 35 and 3) nociceptive. 36 The ability to identify the predominant mechanism-based classification is reliable in patients with nonspecific cervical pain (kappa = .84 ...
... In the absence of red flag findings, nociplastic symptoms are characterized by pain that is disproportionate, nonmechanical, unpredictable, and diffuse. 34 Patients with nociplastic symptoms often have maladaptive behaviors related to the presence of negative beliefs (fear-avoidance), lack of positive beliefs related to self-efficacy, and dyskinetic movement related to kinesiophobia. 34 This cluster of findings was found to have a sensitivity of 91.8% and a specificity of 97.7%. ...
... 34 Patients with nociplastic symptoms often have maladaptive behaviors related to the presence of negative beliefs (fear-avoidance), lack of positive beliefs related to self-efficacy, and dyskinetic movement related to kinesiophobia. 34 This cluster of findings was found to have a sensitivity of 91.8% and a specificity of 97.7%. 34 If a patient has nociplastic mediated pain, it is expected that the physical exam may not significantly change the patient's primary symptomatic complaints. ...
Article
Background There is considerable overlap between pain referral patterns from the lumbar disc, lumbar facets, the sacroiliac joint (SIJ), and the hip. Additionally, sciatic like symptoms may originate from the lumbar spine or secondary to extra-spinal sources such as deep gluteal syndrome (GPS). Given that there are several overlapping potential anatomic sources of symptoms that may be synchronous in patients that have low back pain (LBP), it may not be realistic that a linear deductive approach can be used to establish a diagnosis and direct treatment in this group of patients. Objective The objective of this theoretical clinical reasoning model is to provide a framework to help clinicians integrate linear and non-linear clinical reasoning approaches to minimize clinical reasoning errors related to logically fallacious thinking and cognitive biases. Methods This masterclass proposes a hypothesis-driven and probabilistic approach that uses clinical reasoning for managing LBP that seeks to eliminate the challenges related to using any single diagnostic paradigm. Conclusions This model integrates the why (mechanism of primary symptoms), where (location of the primary driver of symptoms), and how (impact of mechanical input and how it may or may not modulate the patient's primary complaint). The integration of these components individually, in serial, or simultaneously may help to develop clinical reasoning through reflection on and in action. A better understanding of what these concepts are and how they are related through the proposed model may help to improve the clinical conversation, academic application of clinical reasoning, and clinical outcomes.
... A mechanism-based classification approach has been proposed by several different authors [17][18][19][20][21][22][23][24] as an alternative to the traditional temporal-based classification to better inform pain management interventions (see Chapter 96). As the name implies, this approach to classifying pain focuses on identifying the dominant neurophysiological mechanism that is driving the individual's pain experience. ...
... Within this framework, there are three predominant mechanisms: nociception dominant, peripheral neuropathic dominant, and nociplastic dominant (sometimes referred to as central sensitization dominant). [18][19][20]25 ...
... Patients traditionally classified as having chronic pain may have a nociception-dominant or peripheral neuropathic-dominant pain state rather than a nociplastic-dominant pain state. 18,20,22 To further complicate things, it is possible for individuals to present without one clear dominant driver-more of a mixed-driver presentation. 31 Although there remains no agreed upon gold standard test for the identification of nociplastic or central sensitization-dominant pain, the Delphi-derived clinical signs and symptoms 32 that have been shown to be most predictive of central sensitization-or nociplastic-dominant pain are listed in Box 94.3. ...
... [11][12][13] A novel idea for effective pain control is focused on identifying one of the three possible pain mechanisms: nociceptive, neuropathic, or nociplastic. 1,[14][15][16] Thus, the treatment would follow the pain type. The problem of determining the dominant pain component, however, has not yet been solved. ...
... The problem of determining the dominant pain component, however, has not yet been solved. 1,14,15 To identify patients who present with symptoms related to central sensitization (nociplastic pain), the patient-reported history, questionnaires, and quantitative sensory testing (QST) are recommended. Unfortunately, there is a lack of directly measurable parameters allowing the confirmation of nociplastic pain. ...
Article
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Background: The newly proposed low back pain treatment requires case classification according to the pain mechanism (nociceptive, neuropathic or nociplastic) to determine the most effective therapeutic approach. However, there is a lack of objective tools for distinguishing these pain mechanisms. The aim of the study was to identify which symptoms, signs, and standard diagnostic parameters would allow predicting the nociplastic pain (NP) subtype among low back leg pain (LBLP) patients. Methods: A retrospective analysis of an LBLP case-control study database was carried out. The presence of NP was assumed if the patient presented with myofascial pain syndrome (MPS) and developed a short-term intensive vasodilatation reaction in the perceived lower leg pain area after provocation by a minimally invasive procedure. Clinical data and standard LBLP diagnostic parameters were analyzed to classify patients as NP (+) vs NP (-). Next, to predict NP probability, logistic regression analysis and a diagnostic classification tree were constructed. Results: NP was confirmed in 43.75% of LBLP patients. Women represented 95.24% of all NP (+) patients. The diagnostic classification tree indicated that NP was highly probable if the LBLP subject was female and the result of a positive straight leg raise (SLR) test was lower than 45 degrees. If the SLR test result was greater than or equal to 45 degrees, a negative result on the Bragard test would have diagnostic value. This classification tree was approved to a certain extent in the logistic regression model (deviance residuals, min: -1.8519; 1Q: -0.5551; median: -0.1907; 3Q: 0.6565 and max: 2.1058) but should be verified in a larger group of subjects. Conclusion: Female sex, but not clinical data or standard diagnostic parameters, is indicative of nociplastic pain in LBLP patients. More sophisticated statistical methods, based on directly measurable parameters, should be proposed to distinguish NP involvement in LBLP.
... 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.
... The persistent feature of pain has been associated with the CS. Several studies in patients with musculoskeletal pain revealed the implication of the CS in the perception of pain in patients with musculoskeletal conditions [6][7][8][9]. A narrative review revealed that these conditions were categorized as psychosomatic, functional, somatization, and medically unexplained disorders [10]. ...
... Clinical indicators showed high reliability in patients with low back pain [21] and patients with nonspecific neck pain [22]. Besides, clinical indicators have been recommended for the management of low back pain [9], nonspecific shoulder pain [23], and chronic pain related to osteoarthritis [24]. Although the clinical indicators are based on the perspectives of clinicians, our group found similar prevalence of patients with CSrelated sign and symptoms (21%) [16] and impaired CPM (25%) [25] in patients with musculoskeletal pain. ...
Article
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Background The identification of central sensitization (CS) is an important aspect in the management of patients with chronic musculoskeletal pain. Several methods have been developed, including clinical indicators and psychophysical measures. However, whether clinical indicators coincide with the psychophysical test of CS-related sign and symptoms is still unknown. Therefore, the present study aimed to analyze the diagnostic accuracy of the clinical indicators in identifying CS-related sign and symptoms in patients with musculoskeletal pain. Methods One-hundred consecutive patients with musculoskeletal pain were included. Clinical indicators (index method) based on a combination of patient self-report pain characteristics and physical examination were used to identify the phenotype of patients with musculoskeletal pain and the predominance of the CS-related sign and symptoms. Conditioned pain modulation (CPM) was assessed by the Cold Pressor Test (reference standard), which is a psychophysical test used to detect impairment of CPM. Measurements of the diagnostic accuracy were performed. Results Twenty-seven patients presented predominance of CS-related sign and symptoms in the assessment of the clinical indicators, and 20 had impairment of CPM. Clinical indicators showed high accuracy (75.0%; 95% confidence interval = 65.3 to 83.1), high specificity (80.0%; 95% confidence interval = 69.6 to 88.1), high negative predictive value (87.7%; 95% confidence interval = 81.2 to 92.1), and a relevant positive likelihood ratio (2.8, 95% confidence interval = 1.5 to 5.0) when compared to the Cold Pressor Test. Conclusion Clinical indicators demonstrated a valuable tool for detecting the impaired CPM, which is a remarkable feature of the CS-related sign and symptoms. Clinicians are encouraged to use the clinical indicators in the management of patients with musculoskeletal pain.
... 288 Central sensitization should be strongly suspected in those with lowback related leg pain with disproportionate, nonmechanical, and unpredictable patterns of pain provocation in response to multiple non-specific aggravating or easing factors. 292 Patients with chronic pain may benefit from TNE. 284,293,294 Patients with chronic pain often have central sensitization. 293 One study found that LBP spreading to the upper back increased the odds of chronic pain. ...
Chapter
• The treatment of sciatica differs according to its cause • Most cases warrant a trial of conservative treatment • Integrated programs including manual therapies and exercise may be superior to any single therapy • Surgery is indicated in the presence of red flags and/or a lack of response to conservative treatment
... Psychometric instruments have been designed to assess the presence of CS in people with chronic pain. Of these studies, two evaluate symptoms in specific anatomical locations: the Clinical Classification of CS pain in patients with low back (±leg) pain [8] and the Allodynia Symptom Checklist that reports cutaneous allodynia in people with headache [9]. Alternatively, the Central Sensitivity Inventory evaluates somatic and other health-related symptoms thought to be common to conditions associated with CS [10]. ...
Article
Background and aims: The purpose of this study was to (a) develop and (b) conduct exploratory factor analysis on a novel self-report instrument for symptoms associated with altered central pain processing. Methods: We first developed a 25-item questionnaire based on previous literature identifying symptoms and behaviours that may reflect altered spinal and supraspi-nal pain processing. We then administered this questionnaire to 183 people with chronic pain (n = 99) and healthy individuals (n = 84). Exploratory factor analysis was conducted to identify the factor structure of the questionnaire. Results: Our results support a two-factor solution for the 25-item questionnaire that accounted for 57.2% of the total variance of responses in people with and without chronic pain. Factor one (11 items) included items related to alterations in sensation of pain, while factor two (seven items) included items associated with emotional and fatigue symptoms. Seven items showed weak factor load-ings and were eliminated. Reliability was excellent, while both factors showed strong correlations with previously-validated self-report Instruments: (pain catastrophising, mood, vigilance, pain self-efficacy) and conditioned pain modulation, providing evidence for their validity. Conclusions: We have developed a questionnaire containing two factors that appear to be related to two different symptom clusters, one of which is specifically related to pain and one of which contains other health-related symptoms related to mood and fatigue. These factors show excellent internal consistency and validity. This questionnaire may be a quick, easy and reliable instrument to assess central pain processing in clinical settings.
... Identifying reference clinical symptoms and signs, however, may indicate the presence of CS: disproportionate pain, diffuse distribution, allodynia and hyperalgesia, hypersensitivity unrelated to mechanical stimulus but rather to environmental sensations (light, temperature, noise or other stressors), maladaptive psychosocial factors and low vagal nerve activity. [13][14][15][16] Chronic pain is a multifactorial condition which has an impact on physical or body structures and functions, on psychological processes and on daily activities and quality of life of individuals. 2 17 18 Limited functioning or capacity to perform everyday tasks (essential for an independent living) affects individuals with chronic pain in their mobility and self-care, social relationships, work and leisure. ...
Article
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Introduction A relevant subsample of patients with chronic low back pain (CLBP) have manifested augmented central pain processing, central sensitisation (CS). Patients with CLBP have limited functioning and participation. Theoretically, physical functioning in patients with CLBP can plausibly be linked to CS; however, evidence to explain such association is scarce. Moreover, there is no gold standard for CS diagnosis. The objectives of the study are: (1) to analyse the association between instruments assessing reference symptoms and signs attributed to CS; (2) to analyse whether reference symptoms and signs attributed to CS are associated with functioning measurement outcomes; and (3) to analyse whether changes (between baseline and discharge) in reference symptoms and signs attributed to CS are related to changes in each of the functioning measurement outcomes. Methods and analysis A cross-sectional and longitudinal observational study is performed with measurements taken at baseline and discharge of an interdisciplinary rehabilitation programme. A sample size of 110 adult patients with CLBP has been calculated for the study. CS measurements are: Central Sensitisation Inventory, quantitative sensory testing and heart rate variability. Functioning measurements are: lifting capacity, maximal aerobic capacity, accelerometry and reported functioning. Statistical analyses to be performed are: (1) correlation between CS measurements, (2) multiple regression between functioning (dependent variable) and CS measurements (independent variable), and (3) multiple regression between changes in scores of functioning (dependent variable) and CS measurements (independent variable), and corrected for sex and age. Ethics and dissemination The study obtained the clearance to its implementation from the Medical Research Ethics Committee of the University Medical Center Groningen in July 2017. The results will be disseminated through scientific publications in peer-reviewed journals, presentations at relevant conferences, and reports to stakeholders. Trial registration number NTR7167/NL6980.
... 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.
... this narrative review aims (1) to provide an overview of the existing knowledge in the literature on the interaction between nutrition and chronic musculoskeletal pain (i.e., inflammation, obesity, homeostatic balance, and central sensitization as underlying mechanisms) 10 and (2) to identify applications of nutritional behavior and dietary intake assessments and interventions for chronic musculoskeletal pain in clinical practice. ...
Article
Nutrition is one of the most important lifestyle factors related to chronic diseases such as cancer, diabetes, and cardiovascular diseases. Additionally, poor diet is also considered a predicting, perpetuating, or underlying factor in chronic musculoskeletal pain. This narrative review provides an overview of current knowledge on the relationship between nutrition and chronic musculoskeletal pain (ie, inflammation, obesity, homeostatic balance, and central sensitization as underlying mechanisms). This review also identifies how dietary intake assessments and nutritional behaviour interventions for chronic musculoskeletal pain can be used in clinical practice and identifies areas in need of additional research. Based on the available literature, dietary behavior and quality could have an impact on chronic musculoskeletal pain conditions, but the direction of this impact is unclear. There is a need for additional human nutrition studies that focus on specific musculoskeletal pain conditions and underlying pathologies. This article is protected by copyright. All rights reserved.
... negative emotions, poor self-efficacy, maladaptive beliefs and pain behaviors);" and "diffuse/non-anatomic areas of pain/tenderness on palpation." 21 if we consider the role of a beta mechanoreceptors as the physical substratum of mechanical allodynia, the blockade of neural conduction should be effective in modulating the afference to wide dynamic range neurons. Consequently, the use of topical lidocaine patch may be considered in presence of allodynic areas, 4 but further data are necessary to support its administration for targeting central sensitization in musculoskeletal pain. ...
Article
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chronic musculoskeletal pain is a highly prevalent condition that is commonly encountered in both general and special- ist practice. Nonetheless, it still represents a significant challenge to the practitioners because of the lack of substantial evidence-based guidance. this review aimed to summarize the main pathophysiological mechanisms of chronic pain of- fering a mechanism-oriented approach to diagnosis and management. We believe that a basic knowledge of the physical signs and symptoms of these mechanisms could empower the clinician to choose appropriate medication and identify high-risk pain patients. Central sensitization and neuropathic features may arise in previously nociceptive and inflamma- tory pain syndromes. central sensitization is a functional remodeling of the spinal cord, where light touch afferents are recruited by nociceptive second-order neurons. Neuropathic features include both negative signs, such as reduced percep- tion of vibration and touch, and positive symptoms, such as paroxysmal electric shock pain, due to ectopic discharge. These phenomena are the neurobiological basis of the commonly defined refractory chronic pain. early detection and specific treatment of these mechanisms are required in order to restrain the reinforcement of pronociceptive remodeling of the nervous system.
... The patient scored high on being significantly impacted by her CLBP. These high scores on psychosocial issues, along with disproportionate pain, disproportionate aggravating and easing factors, and diffuse palpation tenderness, were consistent with the clinical presentation of a nociplastic dominant (central sensitization) clinical presentation [34]. Cognitive Behavioral Therapy (CBT) and PNE have both shown to be a first-choice treatment for patients presenting with a nociplastic pain presentation [11,30]. ...
Article
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We describe the case of a 75-year-old female with chronic low back pain (CLBP), on opioids for more than 15 years. She presented with an acute episode of nausea, vomiting, abdominal pain, and shortness of breath. After a complete work-up, it was concluded that her presenting symptoms were likely due to her high levels of CLBP and high dose opioids. At the time of intervention, her opioid dosage was between 50–90 MME (Morphine milligram equivalent) (Norco 8 × 7.5 mg/day + Fentanyl 12 mcg patch). She was subsequently seen by the physician for seven outpatient internal medicine appointments over nine months and received Pain Neuroscience Education (PNE) in conjunction with monitored tapering of opioids and other medication associated with her CLBP. This case report demonstrates how a physician might deliver PNE as a viable nonpharmacological treatment option for the tapering of long-term opioids for chronic pain.
... 4. Sub-grouping based on pain sensitivity profiling to facilitate recognition of pain sensitivity at an individual level: Sub-grouping people with pain based on their QST profiles has been demonstrated (eg (Arendt-Nielsen et al., 2018;Lluch et al., 2017;Nijs et al., 2014;Rabey, Slater, 2015b;Smart et al., 2012;Vaegter and Graven-Nielsen, 2016;Zusman, 2012), though this can be performed in pain-free individuals as well (Hastie et al., 2005). The clinical utility of sub-groups has not been fully explored and requires further investigation. ...
Article
Introduction Research on musculoskeletal disorders indicates that pain sensitivity can be an important consideration for musculoskeletal clinicians in the holistic view of a patient presentation. However, diversity in research findings in this field can make this a difficult concept for clinicians to navigate. Limited integration of the concept of pain sensitivity into clinical practice for musculoskeletal clinicians has been noted. Purpose The purpose of this masterclass is to provide a framework for the consideration of pain sensitivity as a contributing factor in the presentation of people with musculoskeletal pain. It provides pragmatic synthesis of the literature related to pain sensitivity through a lens of how this information can inform clinical practice for musculoskeletal clinicians. Guidance is provided in a ‘how to’ format for integration of this knowledge into the clinical encounter to facilitate personalised care. Implications The relationship of pain sensitivity with pain and disability is not clear or linear. The real importance of pain sensitivity in a clinical presentation may be: (1) the potential for pain sensitivity to modify the effect of common treatments utilised by musculoskeletal clinicians, or (2) the effect of pain sensitivity on the prognosis/course of a disorder. Screening tools and subjective features have been highlighted to indicate when physical assessment of pain sensitivity should be prioritised in the physical examination. A pragmatic blueprint for specific assessment related to pain sensitivity has been outlined. A framework for integrating assessment findings into clinical reasoning to formulate management plans for the pain sensitive patient is provided.
... 11 Patients who present with central sensitization as their dominant pain mechanism likely require specific/tailored treatment strategies to improve clinical outcomes. 8 Features of central sensitization include symptoms of high severity and irritability, 12 including an increased sensitivity to painful stimuli (hyperalgesia), 13,14 and the maintenance of symptoms in the absence of associated physical damage. 15 A further feature of central sensitization is widespread pain, which is pain experienced beyond the expected anatomical distribution of the pathology. ...
Article
Background: Central sensitization may be present in some patients with hip osteoarthritis (OA), often reflected as widespread pain. We examine the association between pain extent with signs of central sensitization and other clinical and psychological features in patients with hip OA. Methods: Thirty patients with hip OA were recruited for this cross-sectional observational study. Participants completed pain drawings on a digital tablet, which displayed frontal and dorsal views of the body. The pain extent (%) for each participant was determined by combining the frontal and dorsal pixels shaded and dividing by the total pixels of the body chart area. Participants completed patient reported outcome measures to assess for signs and symptoms of central sensitization and psychosocial factors. Quantitative sensory testing including pain pressure thresholds (PPTs) and Thermal Pressure Thresholds (TPTs) was performed at points anatomically local and distant from the hip. Results: Women had significantly greater pain extent (6.71%) than men (2.65%) (z= -2.76, p <0.01). Across all participants, increased pain extent was significantly associated with higher scores on the Widespread Pain Index (r2=0.426, p<0.05), Pain Detect (r2=0.394, p<0.05) and Pain Catastrophising Scale (r2=0.413, p<0.05), and with lower PPTs at the thenar eminence (r2=-0.410, p<0.05), vastus lateralis (r2 =-0.530, p<0.01), vastus medialis (r2=0.363, p<0.05) and greater trochanter (r2=-0.373, p<0.05). Conclusions: Greater pain extent was associated with several measures of signs and symptoms of central sensitization in patients with hip OA. These results support the utility of the pain drawing for identifying signs of central sensitization in patients with hip OA.
... [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.
... 는데 이들은 각각 통증 수용체, 말초신경, 중추 신경이 매개하는 신경생리학적 통증 분류에 해당한다 [4]. 대부분의 ...
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Neuropathic pain is associated with primary lesion or dysfunction of the peripheral and central nerve systems, affecting up to 10% of the general population. Although both nociceptive pain and neuropathic pain utilize the same nervous system pathways, physiologic differences exist in the pathologic mechanism, clinical presentation, and treatments. Ectopic activity in primary afferent fibers, excitatory and inhibitory somatosensory signaling, nociceptive neuron alterations, and central pain modulation have been implicated in neuropathic pain. These neuropathic mechanisms are associated with the complexity of symptoms, difficult treatment decisions, and challenging poor outcomes. Treatment options include pharmacologic (e.g., anticonvulsants, antidepressants, lidocaine, N-methyl-D-aspartate antagonist, opioids), physical, psychological (e.g., cognitive behavioral therapy), or interventional management (e.g., peripheral or neuro-axial nerve blockade, spinal cord stimulators, intrathecal medications). Medication selection should be individualized, considering patients’ symptoms and potential beneficial or deleterious effects (side effects) on comorbidities. The interventional management of chronic neuropathic pain should be considered for patients who have not responded to pharmacologic and non-interventional treatments, as an integral component of a more comprehensive approach. This article presents an overview of physiological mechanisms, clinical presentation, and assessment of neuropathic pain, and discusses treatment options for neuropathic pain.
... 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]. ...
Article
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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
... [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.
... The use of pathophysiological mechanisms to classify pain is more helpful. However, clinical presentations commonly have multiple mechanisms that need to be addressed (Nijs, 2015;Smart et al., 2012) and so defining and attributing pain to a single mechanism is unhelpful and may mislead the clinician's thinking and judgments. ...
Article
Introduction: The Pain and Movement Reasoning Model is a tool to assist clinical reasoning. It was created for physiotherapists to use in musculoskeletal outpatient clinics but may be appropriate in other clinical contexts. The Model has also been used in physiotherapy education.Objective: To determine physiotherapists' perceptions of the appropriateness (suitability) and benefit (utility) of the Pain and Movement Reasoning Model across clinical contexts in hospital and community practice. Methods Physiotherapists from two health networks in Melbourne, Australia, received training in using the Model and over 4-6 weeks applied it in their clinical interactions. Drawing on a deductive phenomenological approach, transcripts from focus groups and interviews were analysed to determine the suitability and utility of the Model across clinical areas.Results: Twenty-nine physiotherapists from 12 different clinical areas participated. Two themes represented the participants' comments: Suitability for Practice and Utility in Practice. Participants reported the approach to clinical reasoning, promoted by the Model, aligned with existing physiotherapy practice. Enhancements to practice included more comprehensive assessment, selection of broader management techniques and increased confidence with reasoning and explaining the complexity of pain to patients. Participants described using the Model for developing junior staff and training postgraduate students. They also saw potential in adapting the Model for other disciplines and for other multifactorial conditions.Conclusion: Physiotherapists working in a range of clinical contexts considered the Pain and Movement Reasoning Model appropriate and beneficial in clinical practice and in teaching. Further evaluation of the Model in wider settings is warranted.
... 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.
... 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.
... [15][16][17] It has been broadly discussed that identification of mechanism and subsequent classification of patients to a pain mechanism category (PMC) may be based on the characteristics of their presentation. [18][19][20][21] On this basis, many different groupings have been proposed with a diversity of terminology and proposed features. 11,15,18 The expansive research on this issue has resulted in considerable confusion. ...
Article
Objectives: Improvements in pain management might be achieved by matching treatment to underlying mechanisms for pain persistence. Many authors argue for a mechanism-based classification of pain, but the field is challenged by wide variation in proposed terminology, definitions and typical characteristics. This study aimed to: (i) systematically review mechanism-based classifications of pain experienced in the musculoskeletal system; (ii) synthesise and thematically analyse classifications, using the International Association for the Study of Pain categories of nociceptive, neuropathic and nociplastic as an initial foundation; and (iii) identify convergence and divergence between categories, terminology, and descriptions of each mechanism-based pain classification. Methods: Databases were searched for papers that discussed a mechanism-based classification of pain experienced in the musculoskeletal system. Terminology, definitions, underlying neurobiology/pathophysiology, aggravating/easing factors/response to treatment, and pain characteristics were extracted and synthesised based on thematic analysis. Results: From 224 papers, 174 terms referred to pain mechanisms categories. Data synthesis agreed with broad classification based on ongoing nociceptive input, neuropathic mechanisms, and nociplastic mechanisms (e.g. central sensitisation). “Mixed”, “other”, and the disputed categories of “sympathetic” and “psychogenic” pain, were also identified. Thematic analysis revealed convergence and divergence of opinion regarding definitions, underlying neurobiology and characteristics. Discussion: Some pain categories were defined consistently, and despite the extensive efforts to develop global consensus on pain definitions, disagreement still exists regarding how each could be defined, subdivided and their characteristic features that could aid differentiation. These data form a foundation for reaching consensus on classification.
Article
Background: Central sensitization (CS) is an important feature in musculoskeletal chronic pain and associated symptoms can be assessed using the Central Sensitization Inventory (CSI). Objectives: This study aimed to translate and cross-culturally adapt the CSI to European Portuguese language and to assess its validity and reliability in adolescents with musculoskeletal chronic pain. Methods: The European Portuguese version of the CSI was established following the translation and testing processes recommended by international guidelines. Then, this version of the CSI was completed by 1730 adolescents, who also completed the Nordic Musculoskeletal Questionnaire; the Pain Catastrophizing Scale; the Depression, Anxiety and Stress Scale; the Tampa Scale of Kinesiophobia, and the Basic Scale on Insomnia Complaints and Quality of Sleep. Test-retest reliability and measurement error, internal consistency, hypothesis testing, and factor analysis were assessed for the translated version of the CSI. Results: Cronbach's alpha was 0.91, ICC was 0.94 (95% CI: 0.90; 0.96), the SEM and SDC were 4.15 and 11.50, respectively. Fair correlations were found between CSI and fear of movement (rs =0.46), sleep (rs =0.46) and catastrophizing (rs =0.49). Moderate to good correlations were found between CSI and depression (rs =0.60), anxiety (rs =0.59) and stress (rs =0.65). Conclusion: The European Portuguese version of the CSI was considered easy to understand and showed very good internal consistency, excellent test-retest reliability and construct validity in a community sample of adolescents with musculoskeletal chronic pain.
Article
Background: Low back pain (LBP) is a very common pain problem in powerlifters. There is a lack of evidence to guide powerlifters and health-care professionals in understanding the role of powerlifting in the development of LBP and treatment of injuries in powerlifters. This study aimed to describe functional impairments and patho-anatomical findings in eight powerlifters with and without LBP. Methods: First, four powerlifters with LBP were recruited. Each powerlifter was then matched with a pain-free lifter (Control) by age, Body Mass Index and competition weight class. They all performed physical performance tests and were examined with magnetic resonance imaging. Four weeks prior to the examination the powerlifters also recorded training load. Powerlifters with LBP were also examined by a physiotherapist in order to define their pain and impairments. Results: The four male powerlifters with LBP had a nociceptive pain associated with non-ideal squatting technique, higher flexibility in their lumbar spine than in their hips and patho-anatomical findings such as degenerated discs (four), spondylolysis (one) and spinal stenosis (one). However, the controls also showed similar functional impairments and patho- anatomical findings. Conclusions: Powerlifters with and without LBP show similar functional impairments and patho-anatomical findings. However, powerlifters' LBP seems associated with pain during movement and loading of the lumbar spine. The association and causation between specific functional impairments, patho-anatomical findings and LBP in powerlifters has to be further investigated in studies including more participants.
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The article presents the research results of psychophysiological state of patients with musculoskeletal diseases suffering from chronic pain who received the complex treatment. The method of “Empatho-techique” was used to eliminate chronic pain for one of the patients’ groups. Objective of research: to investigate the change of psychophysiological state of the patients with diseases of musculoskeletal system suffering from chronic pain at the beginning and at the end of complex therapy course with or without Empatho-technique used. The outcome revealed significant decrease of chronic pain intensity and improvement of their psychophysiological state. The received data confirm the leading chronic pain role in changing of psychophysiological patients’ state and underline the necessity of including the drug-free methods in complex treatment programs. It is also of utmost importance to actively involve medical psychologists and psychotherapists in developing new effective chronic pain treatment methods. Keywords: Empatho-technique, emotional and personal characteristics, Autogenic training, Tropho-tropic activity, Ergo-tropic activity, vegetative coefficient, non-drug methods, multidisciplinary medical center. Vera Aleksandrovna Ishinova, 195256 Russia St-Petersburg, Butlerova str., 13-687, +7 911 232 03 60, e-mail: vaishinova687@yandex.ru________________________________________
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Background Patellofemoral pain (PFP) is defined biomechanically, but is characterised by features that fit poorly within nociceptive pain. Mechanisms associated with central sensitisation may explain why, for some, symptoms appear nociplastic. This study compares psychological and somatosensory characteristics between those with persistent PFP and controls. Methods 150 adults with PFP were compared to 61 controls. All participants completed a survey evaluating participant characteristics, PFP‐related constructs and psychological factors: anxiety, depression, pain catastrophizing, kinesiophobia, pain self‐efficacy. Participants also attended a session of somatosensory testing, which included knee and elbow thermal and mechanical detection and pain thresholds, conditioned pain modulation (CPM), and temporal summation of pain (TSP). Differences were evaluated using analysis of covariance (sex as covariate). Multivariate backward stepwise linear regression examined how psychological and somatosensory variables relate to PFP (Knee injury & Osteoarthritis Outcome Score‐patellofemoral). Results The PFP group had multimodal reduced pain thresholds at the knee and elbow (Standardised Mean Difference (SMD), p: 0.86 to 1.2, <0.001), reduced mechanical detection at the elbow (0.43, 0.01) and higher TSP (0.41, 0.01). CPM was not different. Psychological features demonstrated small effects (0.47‐0.59, 0.01‐0.04). The PFP group had a 55% (95% CI: 0.47 to 0.62) risk of kinesiophobia and an 11% (0.06 to 0.15) reduced pain self‐efficacy risk. Kinesiophobia, knee pressure pain threshold, pain self‐efficacy and pain catastrophizing explained 40% of KOOS‐PF variance (p = <0.001). Conclusions Widespread hyperalgesia and evidence of symptom amplification may reflect nociplastic pain. Clinicians should be aware that kinesiophobia and the nociplastic pain may characterise the condition. Significance (1) Individuals with patellofemoral pain have widespread reduced pain thresholds to pressure and thermal stimuli. (2) Mechanically‐induced pain is likely amplified in those with patellofemoral pain. (3) Pain‐related fear is highly prevalent and helps explain patellofemoral pain‐related disability. What’s already known about this topic? (1) Pressure pain threshold can be lower in individuals with patellofemoral pain. What does this study add? (1) This is the first study to explore a combined range of psychological and psychophysical tests in patellofemoral pain. (2) This study provides strong evidence of nociplastic pain in patellofemoral pain.
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ZUSAMMENFASSUNG Rückenschmerz ist ein häufiges Krankheitsbild in der Gesellschaft und stellt die zweithäufigste Ursache für Berufsunfähigkeit in Deutschland dar. Vor allem akuter Rückenschmerz kann Anzeichen einer behandlungsbedürftigen Situation sein, wichtige Differenzialdiagnosen sollten abgeklärt werden. Häufig chronifizieren Rückenschmerzen im Verlauf. Die beschriebenen Symptome sind meist nicht eindeutig nozizeptiv oder neuropathisch, oft zeigt sich ein Mischbild beider Schmerzkomponenten. Dies spielt eine Rolle bei der Therapie, weshalb wegweisende Symptome erfragt werden sollten. Wichtige Schlüsselwörter, die einen neuropathischen Schmerz vermuten lassen, sind u. a. Brennschmerz und einschießender Schmerz sowie das Auftreten von Parästhesien wie Kribbeln und Ameisenlaufen. Die Schmerztherapie sollte leitliniengerecht erfolgen und aktivierende Maßnahmen beinhalten. Eine regelmäßige Bewertung von Verlauf und Therapie ist erforderlich.
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The aim of this chapter is to provide an overview of the most common, evidence-based techniques and approaches used by physical therapists to evaluate and treat patients with pain. The first section on evaluation includes examination techniques, prognosis, and patient diagnosis/classification. The second section on treatment presents management strategies linked to a pain mechanism classification scheme of nociceptive, neuropathic, or nociplastic pain. Specific recommendations from clinical practice guidelines are included for the physical therapy management of spinal pain, lower extremity osteoarthritis, radiculopathy, carpal tunnel syndrome, fibromyalgia, and complex regional pain syndrome, type I.
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Objective Alteration in somatosensory function has been linked to pain experience in individuals with joint pain. This systematic review aimed to establish the level of evidence of associations between psychological, social, physical activity, and sleep measures andsomatosensory function that assessed via quantitative sensory testing (QST) among individuals withjoint pain. Methods A comprehensive literature search was conducted in six electronic databases from their inception to July 2019. Two reviewers independently assessed the methodological quality using a modified QUIPS tool and supplemented with recommendations from CHARMS checklist and QUADAS‐2 tool. The level of evidence was assessed using the GRADE system.Data were pooled to evaluate the strength of the relationships of interest. Results Seventeen studies related to joint painwere included.Pain catastrophizing, depression, anxiety, and physical activity level have been shown to have a significant(small to fair) associations with several QST measures. Pressure pain thershould (PPT) is the only measure that found to be consistently correlated with all the domains.The overall quality of evidencefor all factorsranged from ‘very low’ to ‘moderate’. Subgroup analysis revealed a stronger associationfor depression and pain catastrophizingand PPT and temporal pain summationin individuals with shoulder pain. Conclusion Psychological factorsand physical activity levelsare associated with somatosensory function in people with joint pain. These factors need to be adjusted when establishing predictive relationships between somatosensory function and pain outcomes in individuals with joint pain.
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Zusammenfassung Bei den pathophysiologischen Mechanismen der zentralen Sensitivierung ist die Sensibilität des ZNS auf einen normalen oder unterschwelligen afferenten Input gesteigert. Dieser Vorgang ist ein potenzieller Mechanismus, der einer Gruppe chronischer Krankheitsbilder unterliegt (Fibromyalgie, Kiefergelenkbeschwerden, Reizdarmsyndrom, Spannungskopfschmerz, andauernde Nacken- und Rückenschmerzen). Aufgrund eines fehlenden Goldstandards für den diagnostischen Prozess war das Ziel dieser Literatursuche, prädiktive Faktoren für eine zentrale Sensibilisierung bei Patienten mit Rückenschmerzen zu identifizieren. Die Recherche nach relevanter Literatur fand in den Datenbanken PubMed, PEDro, CINAHL und Sport Discus statt. Zehn selektierte Arbeiten wiesen auf verschiedene Faktoren für die Bestimmung der zentralen Sensitivierung sowie drei mögliche Klassifizierungssysteme hin.
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Background While the biopsychosocial model is advocated for pain management, biomedical approaches continue to dominate in practice. Understanding musculoskeletal clinicians’ perspectives and practices related to pain can inform training needs to optimize care. Little is known regarding the viewpoint of hand therapists who may not have exposure to modern pain models. Objective To explore hand therapists’ perspectives and practices related to musculoskeletal pain using a biopsychosocial lens. Methods This interpretive descriptive qualitative study was embedded in an explanatory sequential mixed methods design. Thirteen hand therapists in the United States were purposefully sampled based on low and high scores on the Revised Neurophysiology of Pain Questionnaire. Each therapist participated in one semi-structured virtual interview. Data were analyzed using open and a priori codes, which were synthesized into themes that aligned with each domain of the biopsychosocial model. Findings Participants described “balancing local tissues and the brain,” “empowering through education and function,” and “looking beyond the individual.” Recognition of multidimensional components of pain reinforced participants’ awareness that “pain is always real.” Discussion Hand therapists appreciated pain as a multidimensional phenomenon, with biological, psychological, and social facets. However, a potential bias toward structural pathology warrants additional training to promote high-value musculoskeletal care.
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Background: Explaining pain to patients through pain neuroscience education (PNE) is currently a widespread treatment studied in the musculoskeletal context. Presently, there is sufficient evidence supporting the effectiveness of PNE in patients with chronic musculoskeletal disorders. However, clinicians must pay attention to the actual possibility to transfer research findings in their specific clinical context. Objective: We analysed the applicability of results of studies focused on PNE, which has not been done previously. Methods: A detailed discussion on PNE applicability is provided, starting from published randomized controlled trials that investigated the effectiveness of PNE. Results: This paper markedly points out the awareness of clinicians on the need for an accurate contextualization when choosing PNE as an intervention in clinical practice.
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Chronic musculoskeletal pain (CMP) is a common occurrence in clinical practice and there are a variety of options for the treatment of it. However, the pharmacological therapy is still considered to be a primary treatment. The recent years have witnessed the emergence of opioid crisis, yet there are no relevant guidelines on how to treat CMP with non-opioid analgesics properly. The Chinese Medical Association for the Study of Pain convened a panel meeting to develop clinical practice consensus for the treatment of CMP with non-opioid analgesics. The purpose of this consensus is to present the application of nonsteroidal anti-inflammatory drugs, serotonin norepinephrine reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, muscle relaxants, ion channel drugs and topical drugs in CMP.
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Background Further clinical data how low-back pain (LBP) symptoms and signs manifests in physiotherapy clinical reasoning and treatment decision-making is needed. Objective The aim was to explore and describe how symptoms and signs portrayed in three case descriptions of LBP influences physiotherapy treatment decision-making. Design This was an exploratory interview study using inductive content analysis. Method Fifteen semi-structured individual interviews were used to collect data of physiotherapists’ treatment decision-making regrading three diverse LBP case descriptions. The participants were men, women, experienced and novice, working in primary healthcare settings in one sparsely populated region and in one larger city in Sweden. Findings Two overarching themes were identified influencing decision-making for the treatment of LBP:1) Explicit assessment features distinguish treatment approaches; with categories describing how symptoms and signs were used to target treatment (nature of pain induce reflections on plausible cause; narrative details trigger attention and establishes knowledge-enhancing foci; pain-movement-relationship is essential; diverse emphasis of pain modulation and targeted treatment approaches): and 2) Preconceived notion of treatment, with categories describing personal treatment rationales, unrelated to the presented symptoms and signs (passive treatment avoidance and motor control exercise ambiguity). Conclusion This study identifies how assessment details lead to decisions on diverse treatment approaches for LBP, but also that treatment decisions can be based on preconceived beliefs unrelated to the clinical presentation. The results underpin the mix of knowledge sources that clinicians need to balance and the necessity of self-awareness of preconceptions for informed and meaningful clinical decision-making.
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Background Despite the emergence of multiple clinical practice guidelines (CPGs) for the rehabilitation of low back pain (LBP) over the last decade, self‐reported levels of disability in this population have not improved. This may be explained by the numerous implementation barriers such as the complexity of information and sheer volumes of CPGs. Objectives To summarize the evidence and recommendations from the most recent and high‐quality CPGs on the rehabilitation management of LBP by developing an infographic summarizing the recommendations to facilitate dissemination into clinical practice. Methods We performed a systematic review of high‐quality CPGs with an emphasis on rehabilitation approaches. We searched major health‐related research databases (e.g., PubMed, CINAHL, PEDro). We performed quality assessment via the AGREE‐II instrument. Contents of the CPGs were synthesized by extracting recommendations, which were then compared to one another to identify consistencies based on an iterative evaluation process. Results We identified and assessed 5 recent high‐quality CPGs. We synthesized 13 recommendations on the rehabilitation management of LBP (2 for screening procedures, 3 for assessment procedures and 8 involving treatment approaches) and 2 underlying principles were highlighted. These results were then synthetized and illustrated in a concise infographic that serves as a conceptual roadmap that identifies the specific behavior changes (i.e., adoption of CPGs’ recommendations) rehabilitation professionals should adopt in order to integrate an evidenced‐based approach for the management of LBP. Conclusions We systematically reviewed the literature for CPGs’ recommendations for the physical rehabilitation management of LBP and synthesized the information through an infographic.
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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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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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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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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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Political science researchers typically conduct an idiosyn- cratic search of possible model configurations and then present a single specification to readers. This approach systematically understates the uncertainty of our results, generates fragile model specifications, and leads to the estimation of bloated models with too many control vari- ables. Bayesian model averaging (BMA) offers a sys- tematic method for analyzing specification uncertainty and checking the robustness of one's results to alterna- tive model specifications, but it has not come into wide usage within the discipline. In this paper, we introduce important recent developments in BMA and show how they enable a different approach to using the technique in applied social science research. We illustrate the method- ology by reanalyzing data from three recent studies us- ing BMA software we have modified to respect statisti- cal conventions within political science.
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Physiotherapy has long been part of the overall intervention for the attempted rehabilitation of patients with pain and disability following peripheral (and central) nerve damage. In musculoskeletal physiotherapy (a subspecialty), a movement-based assessment and treatment protocol has been devised that is guided by, among other things, therapists' perceptions of patients' responses to mechanical stimuli, including various tests of 'neural tension'. Recently, this process together with provocative tests of sensation has been employed to identify, and predict outcomes for, patients suspected of having a 'neural tissue' component to their pain and consequent disability (either fascicular damage or 'neuritis'). However, some of the syndromes involved are controversial, and uncertainty still surrounds the diagnosis, mechanisms and, therefore, effective treatment of the highly complex symptom, true neuropathic pain. In this review, the current basic scientific evidence for the proposed cause, and often intractable nature, of neuropathic pain is presented and discussed with reference to musculoskeletal therapy. It will be seen that peripheral nerve damage has the potential to create potentially irreversible changes in (peripheral and) central nervous system structure and function that have, to date, largely defied effective medical treatment. For musculoskeletal physiotherapy to discriminate accurately and, where appropriate, intervene (or not) responsibly, it would seem constructive to incorporate this (and other) mechanisms-related evidence into its clinical reasoning and decision-making process.
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Neuropathic pain is common in many diseases or injuries of the peripheral or central nervous system, and has a substantial impact on quality of life and mood. Lesions of the nervous system may lead to potentially irreversible changes and imbalance between excitatory and inhibitory systems. Preclinical research provides several promising targets for treatment such as sodium and calcium channels, glutamate receptors, monoamines and neurotrophic factors; however, treatment is often insufficient. A mechanism-based treatment approach is suggested to improve treatment. Valid and reliable tools to assess various symptoms and signs in neuropathic pain and knowledge of drug mechanisms are prerequisites for pursuing this approach. The present review summarizes mechanisms of neuropathic pain, targets of currently used drugs, and measures used in neuropathic pain trials.
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In this literature review, the mechanisms underlying pain associated with osteoarthritis (OA) are discussed, along with evidence for the efficacy of medications thought to act centrally to relieve OA pain. We survey the cascade of events from inflammation to activation of nociceptive and neuropathic pathways, to the development and maintenance of central and peripheral sensitization. Preclinical and clinical evidence for the sensitization hypothesis is discussed, along with recently identified genetic variations that may increase sensitivity to pain in patients with OA. Evidence is presented for the efficacy of centrally acting analgesics for OA pain (opioids, antiepileptics, tricyclic antidepressants, and serotonin/norepinephrine receptor inhibitors).
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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.