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Evidence and gap maps (EGM) can be used to identify gaps within specific research areas and help guide future research agendas and directions. Currently, there are no EGMs within the broad domain of chronic musculoskeletal (MSK) pain in adults. The aim of this study was to create a contemporary EGM of interventions and outcomes used for research investigating chronic MSK pain. This EGM was based on systematic reviews of interventions published in scientific journals within the last 20 years. Embase, PubMed, the Cochrane Library, and PsycINFO were used to retrieve studies for inclusion. The quality of the included reviews was assessed using AMSTAR-II. Interventions were categorised as either physical, psychological, pharmacological, education/advice, interdisciplinary, or other. Outcomes were categorised using the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations. Of 4299 systematic reviews, 457 were included. Of these, 50% were rated critically low quality, 25% low quality, 10% moderate quality and 15% were rated high quality. Physical interventions (e.g., exercise therapy) and education were the most common interventions reported in 80% and 20% of the studies, respectively. Pain (97%) and physical functioning (87%) were the most reported outcomes in the systematic reviews. Few systematic reviews used interdisciplinary interventions (3%) and economic-related outcomes (2%). This contemporary EGM revealed a low proportion of high-quality evidence within chronic musculoskeletal (MSK) pain. This EGM clearly outlines the lack of high-quality research and the need for increased focus on interventions encompassing the entire biopsychosocial perspective.

Classification of musculoskeletal pain based on underlying pain mechanisms (nociceptive, neuropathic, and nociplastic pain) is challenging. In the absence of a gold standard, verification of features that could aid in discrimination between these mechanisms in clinical practice and research depends on expert consensus. This Delphi expert consensus study aimed to: (1) identify features and assessment findings that are unique to a pain mechanism category or shared between no more than 2 categories and (2) develop a ranked list of candidate features that could potentially discriminate between pain mechanisms. A group of international experts were recruited based on their expertise in the field of pain. The Delphi process involved 2 rounds: round 1 assessed expert opinion on features that are unique to a pain mechanism category or shared between 2 (based on a 40% agreement threshold); and round 2 reviewed features that failed to reach consensus, evaluated additional features, and considered wording changes. Forty-nine international experts representing a wide range of disciplines participated. Consensus was reached for 196 of 292 features presented to the panel (clinical examination-134 features, quantitative sensory testing-34, imaging and diagnostic testing-14, and pain-type questionnaires-14). From the 196 features, consensus was reached for 76 features as unique to nociceptive (17), neuropathic (37), or nociplastic (22) pain mechanisms and 120 features as shared between pairs of pain mechanism categories (78 for neuropathic and nociplastic pain). This consensus study generated a list of potential candidate features that are likely to aid in discrimination between types of musculoskeletal pain.

Background: Musculoskeletal (MSK) injury is one of the major causes of persistent pain. Objective: This systematic literature review explored the factors that lead to persistent pain following a MSK injury in the general population, including athletes. Methods: A primary literature search of five electronic databases was performed to identify cohort, prospective, and longitudinal trials. Studies of adults who diagnosed with a MSK injury, such as sprains, strains or trauma, were included. Results: Eighteen studies involving 5372 participants were included in this review. Participants’ ages ranged from 18–95 years. Most of the included studies were of prospective longitudinal design. Participants had a variety of MSK injuries (traumatic and non-traumatic) causing persistent pain. Multiple factors were identified as influencing the development of persistent pain following a MSK injury, including high pain intensity at baseline, post-traumatic stress syndrome, presence of medical comorbidities, and fear of movement. Scarcity of existing literature and the heterogeneity of the studies made meta-analysis not possible. Conclusions: This systematic review highlighted factors that might help predict persistent pain and disability following MSK injury in the general population, including athletes. Identification of these factors may help clinicians and other health care providers prevent the development of persistent pain following a MSK injury.

Objective The current study aimed to evaluate the concurrent validity and the diagnostic accuracy of the Central Sensitization Inventory (CSI) in detecting the impairment of the pain modulation in patients with chronic musculoskeletal pain. Methods A cross-sectional study was conducted in 267 patients with chronic musculoskeletal pain enrolled consecutively in an outpatient department. The CSI (index method) were compared with the cold pressor test, which was the psychophysical test used to assess the conditioned pain modulation (CPM), (reference standard). Spearman's correlations assessed the concurrent validity, and measurements of the diagnostic accuracy were performed. Results Ninety-three (34.8%) patients had CSI scores ≥ 40. No significant correlation was found between CSI findings and the results of the CPT (dorsal forearm site or tibialis anterior site) was found. The cutoff point of 40 of the CSI showed values of sensitivity (35.1%, 95% CI: 22.6, 49.3) and specificity (65.2%, 95% CI: 58.4, 71.6) below 70%, and an accuracy of 59.1 (95% CI: 53.0, 65.1) when compared to the CPT to detect deficit. The ROC curve analysis yielded an area under the curve of 0.54 (95% CI: 0.45, 0.63, P > 0.05). Conclusions The CSI is a useless instrument to detect the deficit in the CPM in patients with chronic musculoskeletal pain due to the absence of correlation with the psychophysical test result and the insufficient measurements of diagnostic accuracy.

Background The prevention and rehabilitation of multisite musculoskeletal pain would benefit from studies aiming to understand its underlying mechanism. Autonomic imbalance is a suggested mechanism for multisite pain, but hardly been studied during normal daily living. Therefore, the aim of the study is to investigate the association between multisite musculoskeletal pain and cardiac autonomic modulation during work, leisure and sleep. Methods This study is based on data from the “Danish Physical activity cohort with objective measurements” among 568 blue-collar workers. Pain intensity scales were dichotomized according to the median of each scale, and the number of pain sites was calculated. No site was regarded as the pain-free, one site was considered as single-site musculoskeletal pain and pain in two or more sites was regarded as multisite musculoskeletal pain. Heart rate variability (HRV) was measured by an electrocardiogram system (ActiHeart) and physical activity using accelerometers (Actigraph). Crude and adjusted linear mixed models were applied to investigate the association between groups and cardiac autonomic regulation during work, leisure and sleep. Results There was no significant difference between groups and no significant interaction between groups and domains in the crude or adjusted models for any HRV index. Significant differences between domains were found in the crude and adjusted model for all indices, except SDNN; sleep time showed higher values than leisure and work time, except for LF and LF/HF, which were higher during work. Conclusion This cross-sectional study showed that multisite musculoskeletal pain is not associated with imbalanced cardiac autonomic regulation during work, leisure and sleep time. Electronic supplementary material The online version of this article (10.1186/s12891-018-2312-3) contains supplementary material, which is available to authorized users.

Background and aims Musculoskeletal pain may negatively affect work ability, especially when work demands are high and/or physical capacity of the worker is low. This study investigated the association between intensity of musculoskeletal pain in multiple body regions and work ability among young and old workers with sedentary and physical demanding jobs. Methods Currently employed wage earners (n=10,427) replied to questions about pain intensity, work ability, and physical work demands. The odds ratio (OR) for having a lower level of work ability in relation to the physical demands at work were modeled using logistic regression controlled for various confounders. Results The OR for lower work ability increased with higher pain intensity in all regions among workers with sedentary and physical work. The same pattern was observed among workers Conclusions This study shows that increasing pain intensity in multiple sites of the body is associated with lower work ability. This was seen for both younger and older workers as well as those with sedentary and physical work. Implications Physical workers with multiple-site pain may especially be at increased risk of the consequences of reduced work ability. Therefore, extra attention is needed and this group may benefit from better targeted preventive measures.

Background Functional tests are widely used to measure performance in patients with chronic musculoskeletal pain. Our objective was to determine the Minimal Clinically Important Differences (MCID) for the 6-min walk test (6MWT), the Steep Ramp Test (SRT), the 1-min stair climbing test (1MSCT), the sit-to-stand test (STS), the Jamar dynamometer test (JAM) and the lumbar Progressive Isoinertial Lifting Evaluation (PILE) in chronic musculoskeletal pain patients. Methods A single-center prospective observational study was conducted in a rehabilitation center. Patients with upper-limb, lower-limb or neck/back lesions were included over a period of 21 months. We used the anchor-based method as a reference method, supplemented by the distribution-based and opinion-based approaches, to determine the MCIDs. Results 838 chronic musculoskeletal pain patients were included. The estimation method and thelesion location had a significant influence on the results. MCIDs were estimated at +75m and +60m for the 6MWT (lower-limb and neck/back lesions, respectively), +18 steps for the 1MSCT (lower-limb and neck/back lesions) and +6kg for the JAM (upper limb lesions). The anchor-based method could not provide valid estimations for the three other scales, but distribution and opinion-based methods provided rough values of MCIDs for the SRT (+39w to +61w), the STS (-5 sec to -7 sec) and the PILE (+4kg to +7kg). Conclusion The above MCID estimations for the 6MWT, 1MSCT and JAM can be used in chronic musculoskeletal pain patients participating in vocational multidisciplinary rehabilitation programs or in therapeutic trials. The use of specific anchors might give better estimations of MCIDs for the three other scales in future research.

Background Pain catastrophizing is highly relevant to assess in the context of long-standing pain. The Pain Catastrophizing Scale (PCS) is a well-established questionnaire used to measure catastrophizing in individuals with long-standing pain. So far, no Swedish translation has been evaluated in regard to validity and reliability. The aims of this study were to translate the PCS questionnaire from English to Swedish, and to investigate its construct validity (face, content, and structural validity) and reliability (internal consistency). Methods We translated the original English version of the PCS to Swedish and collected item responses from 194 persons suffering from primarily long-standing musculoskeletal pain. We used confirmatory factor analysis to evaluate structural validity, and tested the model fit of a one-factor model, an oblique two-factor model, and an oblique three-factor model. We evaluated the measure's reliability in regard to internal consistency calculated with Cronbach's alpha. Results A three-factor model comprising a four-item rumination factor, a three-item magnification factor, and a six-item helplessness factor provided the best fit to the data. Internal consistency was adequate and Cronbach's α was 0.92 for the entire scale, 0.84 for the rumination subscale; 0.69 for the magnification subscale, and 0.89 for the helplessness subscale. Conclusions The results indicated adequacy of a three-factor solution and the questionnaire's internal consistency, and provide initial support for the structural validity and internal consistency of a Swedish version of the PCS. Future studies should replicate the study in larger samples and extend the current evaluation in regard to validity and reliability.

A common complaint from children is growing pains: a mild to severe pain located primarily in the legs and being most intense in evenings and during sleep. The diagnosis is based on the characteristics of the pain and careful clinical examination. The pain disappears as the child grows up. Research has suggested that the pain occurs more often in children who suffer from vitamin D deficiency, low bone density, low pain threshold, restless legs syndrome and in children who were breastfed for less than 40 days from birth. There are not yet any firm conclusions about the aetiology.

Compelling evidence has shown chronic widespread and exaggerated pain experience in chronic musculoskeletal pain (MSKP) conditions. In addition, neuroimaging research has revealed morphological and functional brain alterations in these patients. It is hypothesized that brain alterations play a role in the persistent pain complaints of patients with chronic MSKP. Nevertheless, lack of overview exists regarding the relations between brain alterations and clinical measures of pain. The present systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, to investigate the relations between structural or functional brain alterations, using magnetic resonance imaging scans, and clinical pain measures in patients with chronic MSKP. PubMed, Web of Science, Cinahl, and Cochrane databases were searched. First, the obtained articles were screened according to title and abstract. Second, the screening was on the basis of full-text. Risk of bias in included studies was investigated according to the modified Newcastle-Ottawa Scale. Twenty studies met the inclusion criteria. Moderate evidence shows that higher pain intensity and pressure pain sensitivity are related to decreased regional gray matter (GM) volume in brain regions encompassing the cingulate cortex, the insula, and the superior frontal and temporal gyrus. Further, some evidence exists that longer disease duration in fibro-myalgia is correlated with decreased total GM volume. Yet, inconclusive evidence exists regarding the association of longer disease duration with decreased or increased regional GM volume in other chronic MSKP conditions. Inconclusive evidence was found regarding the direction of the relation of pain intensity and pressure pain sensitivity with microstructural white matter and functional connectivity alterations. In conclusion, preliminary to moderate evidence demonstrates relations between clinical pain measures, and structural and functional connectivity alterations within brain regions involved in somatosensory, affective, and cognitive processing of pain in chronic MSKP. Nevertheless, inconclusive results exist regarding the direction of these relations. Further research is warranted to unravel whether these brain alterations are positively or negatively correlated to clinical pain measures. Perspective: Structural and functional brain alterations within regions involved in somatosensory, affective, and cognitive pain processing play a crucial role in the persistent pain of chronic MSKP patients. Accordingly, these brain alterations have to be taken into account when assessing and treating patients with chronic MSKP. (C) 2016 by the American Pain Society

Chronic musculoskeletal pain is linked with sensitization, and standardized methods for assessment are needed. This study investigated (1) the test-retest reliability of computer-controlled cuff-pressure algometry (pain thresholds and temporal pain summation) on the arm and leg and (2) conditioned pain modulation (CPM) assessed by cuff algometry. The influences of age and gender were evaluated. On 2 different days, cuff pain threshold (cPPT), cuff pain tolerance (cPTT), and temporal summation of pain (TSP) by visual analog scale scores to 10 repeated cuff stimulations at cPTT intensity, as well as pressure pain threshold with handheld pressure algometry, were assessed in 136 healthy subjects. In one session, cuff pain sensitivity was also assessed before and after cold pressor-induced CPM. Good-to-excellent intraclass correlations (0.60-0.90) were demonstrated for manual and cuff algometry, and no systematic bias between sessions was found for cPPT, cPTT, and TSP on the leg and for cPTT and TSP on the arm. Cuff pressure pain threshold and cPTT were higher in men compared with women (P < 0.05). Middle-aged subjects had higher pressure pain threshold, but lower cPPT and cPTT, compared with younger subjects (P < 0.05). Temporal summation of pain was increased in women compared with men (P < 0.05). Cuff algometry was sensitive to CPM demonstrated as increased cPPT and cPTT and reduced TSP (P < 0.05). Reliability and sensitivity of computer-controlled cuff algometry for pain assessment is comparable with manual pressure algometry and constitutes a user-independent method for assessment of pain. Difference in age-related pain sensitivity between manual and cuff algometry should be further investigated.

The aim was to determine the effect of one weekly hour of specific strength training within working hours, performed with the same total training volume but with different training frequencies and durations, or with different levels of supervision, on compliance, muscle health and performance, behavior and work performance. In total, 573 office workers were cluster-randomized to: 1 WS: one 60-min supervised session/week, 3 WS: three 20-min supervised sessions/week, 9 WS: nine 7-min supervised sessions/week, 3 MS: three 20-min sessions/week with minimal supervision, or REF: a reference group without training. Outcomes were diary-based compliance, total training volume, muscle performance and questionnaire-based health, behavior and work performance. Comparisons were made among the WS training groups and between 3 WS and 3 MS. If no difference, training groups were collapsed (TG) and compared with REF. Results demonstrated similar degrees of compliance, mean(range) of 39(33-44)%, and total training volume, 13.266(11.977-15.096)kg. Musculoskeletal pain in neck and shoulders were reduced with approx. 50% in TG, which was significant compared with REF. Only the training groups improved significantly their muscle strength 8(4-13)% and endurance 27(12-37)%, both being significant compared with REF. No change in workability, productivity or self-rated health was demonstrated. Secondary analysis showed exercise self-efficacy to be a significant predictor of compliance. Regardless of training schedule and supervision, similar degrees of compliance were shown together with reduced musculoskeletal pain and improved muscle performance. These findings provide evidence that a great degree of flexibility is legitimate for companies in planning future implementation of physical exercise programs at the workplace. ClinicalTrials.gov, number NCT01027390.

Multisite musculoskeletal pain is common among people suffering from low back pain. Although the mechanisms behind co-occurrence of multiple somatic symptoms and musculoskeletal pain are still unknown, patients with co-morbidities and co-occurring musculoskeletal symptoms tend to have worse functional status, a poorer prognosis and respond less favourably to treatment. Evidence also suggests that the more pain sites a patient reports, the more reduced their physical and mental function will be regardless of location of pain. At the same time, evidence suggests that strategies for diagnosis and treatment of low back pain and other musculoskeletal disorders such as neck pain and lower limb osteoarthritis are very similar. In this chapter, we discuss the prevalence, consequences, and implications of commonalities between low back pain, pain in other sites and co-occurring pain. In addition, we propose a conceptual framework for a common stepwise approach to the diagnosis and management of back and musculoskeletal pain.