Search

Objective: To investigate the impact of varus malalignment of the knee on pain reduction achieved by an ankle-foot orthosis and a laterally wedged insole in patients with medial knee osteoarthritis. Design: Secondary analysis of a randomized, clinically prospective cross-over study. Patients: Twenty-eight participants with medial knee osteoarthritis. Methods: All participants wore a 5-mm laterally wedged insole and an ankle-foot orthosis for a period of 6 weeks each in a randomized order. Pain was reported on a numerical rating scale and was correlated with limb alignment, as defined by the mechanical axis deviation in full-leg standing radiographs. Results: Insole and orthosis use reduced pain compared with baseline (median knee pain change: insole –0.5 (–5 to +6), orthosis –1.5 (–7 to +5). A higher mechanical axis deviation (greater varus) correlated significantly with smaller pain reduction for both aids (insole p = 0.003, orthosis p < 0.001). A cut-off to predict pain response was found at a mechanical axis deviation of 14–15 mm for both aids, i.e. > 3° knee varus. Conclusion: There is a correlation between varus malalignment and pain reduction. There seems to be a mechanical axis deviation cut-off that predicts the response to treatment with the aids with good sensitivity. LAY ABSTRACT Osteoarthritis of the knee can be treated using orthoses and insoles to unload the most damaged and painful inner (medial) part of the knee. However, patients do not benefit equally from these devices and there is not enough scientific data to predict which patients will benefit from an orthosis or insole. This study investigated whether the genu varum (degree of bow-leggedness) correlates with pain reduction when using an insole or an ankle-foot orthosis. A total of 28 patients with knee osteoarthritis received both aids, each for a period of 6 weeks, in random order. They documented knee pain before and after using the devices. Radiographs of the leg were analysed to determine the degree of genu varum. Statistical analysis showed that patients with straighter legs experienced better pain reduction with both aids than did bow-legged patients. In conclusion, ankle-foot orthoses and insoles are less effective in bow-legged patients.

The effects of exercise interventions on unspecific chronic low back pain (CLBP) have been investigated in many studies, but the results are inconclusive regarding exercise types, efficiency, and sustainability. This may be because the influence of psychosocial factors on exercise induced adaptation regarding CLBP is neglected. Therefore, this study assessed psychosocial characteristics, which moderate and mediate the effects of sensorimotor exercise on LBP. A single-blind 3-arm multicenter randomized controlled trial was conducted for 12-weeks. Three exercise groups, sensorimotor exercise (SMT), sensorimotor and behavioral training (SMT-BT), and regular routines (CG) were randomly assigned to 662 volunteers. Primary outcomes (pain intensity and disability) and psychosocial characteristics were assessed at baseline (M1) and follow-up (3/6/12/24 weeks, M2-M5). Multiple regression models were used to analyze whether psychosocial characteristics are moderators of the relationship between exercise and pain, meaning that psychosocial factors and exercise interact. Causal mediation analysis were conducted to analyze, whether psychosocial characteristics mediate the exercise effect on pain. A total of 453 participants with intermittent pain (mean age = 39.5 ± 12.2 years, f = 62%) completed the training. It was shown, that depressive symptomatology (at M4, M5), vital exhaustion (at M4), and perceived social support (at M5) are significant moderators of the relationship between exercise and the reduction of pain intensity. Further depressive mood (at M4), social-satisfaction (at M4), and anxiety (at M5 SMT) significantly moderate the exercise effect on pain disability. The amount of moderation was of clinical relevance. In contrast, there were no psychosocial variables which mediated exercise effects on pain. In conclusion it was shown, that psychosocial variables can be moderators in the relationship between sensorimotor exercise induced adaptation on CLBP which may explain conflicting results in the past regarding the merit of exercise interventions in CLBP. Results suggest further an early identification of psychosocial risk factors by diagnostic tools, which may essential support the planning of personalized exercise therapy.Level of Evidence: Level I.Clinical Trial Registration: DRKS00004977, LOE: I, MiSpEx: grant-number: 080102A/11-14. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00004977.

Introduction:. The opioid epidemic in North America challenges national guidelines worldwide to define the importance of opioids for the management of chronic noncancer pain (CNCP). Methods:. The second update of the German guidelines on long-term opioid therapy for CNCP was developed by 26 scientific associations and 2 patient self-help organizations. A systematic literature search in CENTRAL, Medline, and Scopus (to May 2019) was performed. Meta-analyses of randomized controlled trials and open-label extension studies with opioids for CNCP were conducted. Levels of evidence were assigned according to the Oxford Centre for Evidence-Based Medicine classification system. The formulation and strength of recommendations were established by multistep formalized procedures to reach a consensus according to German Association of the Medical Scientific Societies regulations. The guidelines underwent external review by 4 experts and public commentary. Results:. Opioids are one drug-based treatment option for short- (4–12 weeks), intermediate- (13–26 weeks), and long-term (>26 weeks) therapy of chronic pain in osteoarthritis, diabetic polyneuropathy, postherpetic neuralgia, and low back pain. Contraindications are primary headaches, functional somatic syndromes, and mental disorders with the (cardinal) symptom of pain. For specified other clinical pain conditions, short- and long-term therapy with opioids should be evaluated on an individual basis. Long-term therapy with opioids is associated with relevant risks. Conclusion:. Responsible application of opioids requires consideration of possible indications and contraindications, as well as regular assessment of clinical response and adverse effects. Neither uncritical opioid prescription nor general rejection of opioids is justified in patients with CNCP.

BackgroundUse of the arm above shoulder level has been described as a risk factor for developing rotator cuff tears (RCT). There is a lack of information regarding the frequency and distribution of RCT in a population using their arms above shoulder level during daily work. The aim of this study was to analyze clinical and radiographic findings in a population of painters working more than 10 years and to compare the results with a control group (CG).Materials and methods100 individuals working more than 10 years as a painter were compared to 100 matched controls without using their arms above shoulder level. MRI scans were performed in all participants. Clinically, the Constant score, DASH score and range of motion (ROM) of the shoulders were analyzed.ResultsIn the painter group (PG) a tear of the supraspinatus tendon was detected in 45% (10%full-thickness; 35% partial) compared to 8% in the (CG) (3% full-thickness; 5%partial; pConclusionLong-term occupational load on the shoulders in painters seems to be associated with an increased risk for developing RCT. Our findings may provide support for developing preventive strategies for this unique cohort. Level of evidence: III.

[This corrects the article DOI: 10.1371/journal.pone.0213824.].

Abstract. Introduction:. Chronic low back pain (LBP) is a major cause of disability; early diagnosis and stratification of care remain challenges. Objectives:. This article describes the development of a screening tool for the 1-year prognosis of patients with high chronic LBP risk (risk stratification index) and for treatment allocation according to treatment-modifiable yellow flag indicators (risk prevention indices, RPI-S). Methods:. Screening tools were derived from a multicentre longitudinal study (n = 1071, age >18, intermittent LBP). The greatest prognostic predictors of 4 flag domains (“pain,” “distress,” “social-environment,” “medical care-environment”) were determined using least absolute shrinkage and selection operator regression analysis. Internal validity and prognosis error were evaluated after 1-year follow-up. Receiver operating characteristic curves for discrimination (area under the curve) and cutoff values were determined. Results:. The risk stratification index identified persons with increased risk of chronic LBP and accurately estimated expected pain intensity and disability on the Pain Grade Questionnaire (0–100 points) up to 1 year later with an average prognosis error of 15 points. In addition, 3-risk classes were discerned with an accuracy of area under the curve = 0.74 (95% confidence interval 0.63–0.85). The RPI-S also distinguished persons with potentially modifiable prognostic indicators from 4 flag domains and stratified allocation to biopsychosocial treatments accordingly. Conclusion:. The screening tools, developed in compliance with the PROGRESS and TRIPOD statements, revealed good validation and prognostic strength. These tools improve on existing screening tools because of their utility for secondary preventions, incorporation of exercise effect modifiers, exact pain estimations, and personalized allocation to multimodal treatments.

BackgroundAttachment insecurity relates to the onset and course of chronic pain via dysfunctional reactions to pain. However, few studies have investigated the proportion of insecure attachment styles in different pain conditions, and results regarding associations between attachment, pain severity, and disability in chronic pain are inconsistent. This study aims to clarify the relationships between insecure attachment and occurrence or severity of chronic pain with and without clearly defined organic cause. To detect potential differences in the importance of global and romantic attachment representations, we included both concepts in our study.Methods85 patients with medically unexplained musculoskeletal pain (UMP) and 89 patients with joint pain from osteoarthritis (OA) completed self-report measures of global and romantic attachment, pain intensity, physical functioning, and depression.ResultsPatients reporting global insecure attachment representations were more likely to suffer from medically unexplained musculoskeletal pain (OR 3.4), compared to securely attached patients. Romantic attachment did not differ between pain conditions. Pain intensity was associated with romantic attachment anxiety, and this relationship was more pronounced in the OA group compared to the UMP group. Both global and romantic attachment anxiety predicted depression, accounting for 15% and 17% of the variance, respectively. Disability was independent from attachment patterns.ConclusionsOur results indicate that global insecure attachment is associated with the experience of medically unexplained musculoskeletal pain, but not with osteoarthritis. In contrast, insecure attachment patterns seem to be linked to pain intensity and pain-related depression in unexplained musculoskeletal pain and in osteoarthritis. These findings suggest that relationship-informed focused treatment strategies may alleviate pain severity and psychological distress in chronic pain independent of underlying pathology.

Despite the fact that unspecific low back pain is of important impact in general health care, this pain condition is often treated insufficiently. Poor efficiency has led to the necessity of guidelines addressing evidence-based strategies for treatment of lower back pain (LBP). We present some statements of the German medical care reality. Self-responsible action of the patient should be supported while invasive methods in particular should be avoided due to lacking evidence in outcome efficiency. However, it has to be stated that no effective implementation strategy has been established yet. Especially, studies on the economic impact of different implementation strategies are lacking. A lack of awareness of common available guidelines and an uneven distribution of existing knowledge throughout the population can be stated: persons with higher risk suffering from LBP by higher professional demands and lower educational level are not skilled in advised management of LBP. Both diagnostic imaging and invasive treatment methods increased dramatically leading to increased costs and doctor workload without being associated with improved patient functioning, severity of pain or overall health status due to the absence of a functioning primary care gate keeping system for patient selection. Opioids are prescribed on a grand scale and over a long period. Moreover, opioid prescription is not indicated properly, when predominantly persons with psychological distress like somatoform disorders are treated with opioids.