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Objective: Previous studies evaluating interdisciplinary multimodal interventions for chronic spinal pain often excluded patients with comorbid mental disorders. This study aims to assess the effectiveness of an outpatient secondary care interdisciplinary multimodal integrative healthcare program for individuals experiencing co-occurring chronic spinal pain and mental disorders., Methods: Participants were 944 patients with chronic spinal pain and comorbid mental disorders. Primary outcomes were health-related quality of life, assessed using the Research and Development-36 (RAND-36), and pain-related disability, assessed using the Quebec Back Pain Disability Scale (QBPDS). Secondary outcomes included pain intensity, pain catastrophizing, kinesiophobia, fatigue, lumbar mobility, and isometric strength. Data were collected during the healthcare program at four time points: pretreatment (T0), midway through 20-week treatment (T1), end of 20-week treatment (T2), and at completion of 12-month relapse prevention program (T3). Multilevel regression analyses were conducted to examine the effects of the healthcare program on primary outcomes over time., Results: The 20-week treatment period yielded significant improvements in both mental ( B = 0.44, t (943) = 19.42, p < .001) and physical component summary scores ( B = 0.45, t (943) = 18.24, p < .001) of the RAND-36, as well as in QBPDS total score ( B = -0.77, t (943) = -26.16 p < .001). Pretreatment scores indicated the presence of problematic fatigue, kinesiophobia, and clinical levels of pain catastrophizing, all of which resolved by the end of the 12-month relapse prevention program., Conclusions: An interdisciplinary multimodal integrative healthcare program seems effective for patients with chronic spinal pain and comorbid mental disorders., (Copyright © 2024 by the American Psychosomatic Society.)

Purpose: The purpose of this paper was first to gain an in-depth understanding of the barriers and facilitators to implementing the BPS model and pain neuroscience education in the current Lebanese physical therapy health care approach and explore its acceptability., Method: A qualitative semi-structured interview using purposive sampling was conducted with eight Lebanese physical therapists practising in different governorates. The transcribed text from the interviews was analyzed using inductive thematic analysis., Results: Two topics were generated and constructed by the researchers: (1) "barriers to the implementation of pain neuroscience education, with subthemes including (a) "current health care approach," (b) "basic curriculum and continuing education," (c) "patients' barriers"; (2) "facilitators to the implementation of pain neuroscience education," with subthemes containing (a) "interest in the BPS model, (b) "therapeutic alliance," and (c) "motivation for future training on BPS approach.", Conclusion: The analysis of the results showed that Lebanese physical therapists currently hold a strong biomedical view of chronic pain, assessment, and treatment. However, despite the presence of barriers and challenges, they are aware and open to consider the implementation and future training about the BPS model and pain neuroscience education in their approach.IMPLICATIONS FOR REHABILITATIONThe exploration of potential barriers and facilitators to the bio-psychosocial model and pain neuroscience education implementation may provide an opportunity for better development and design of a culturally sensitive pain neuroscience education material for Arab-speaking and Lebanese physical therapists.The exploration of barriers and facilitators to the implementation of pain neuroscience education will help to improve pain education and ensure better clinical pain management.The most important barriers were the dominant characteristic of the Lebanese physical therapist's health approach, which is focused on a biomechanically oriented model, and their lack of knowledge to approach chronic pain from a biopsychosocial perspective.

Pain is one of the most important yet poorly understood complaints in heritable connective tissue disorders (HCTDs) caused by monogenic defects in extracellular matrix molecules. This is particularly the case for the Ehlers-Danlos syndrome (EDS), paradigm collagen-related disorders. This study aimed to identify the pain signature and somatosensory characteristics in the rare classical type of EDS (cEDS) caused by defects in type V or rarely type I collagen. We used static and dynamic quantitative sensory testing and validated questionnaires in 19 individuals with cEDS and 19 matched controls. Individuals with cEDS reported clinically relevant pain/discomfort (Visual Analogue Scale ≥5/10 in 32% for average pain intensity the past month) and worse health-related quality of life. An altered somatosensory profile was found in the cEDS group with higher (P = .04) detection thresholds for vibration stimuli at the lower limb, indicating hypoesthesia, reduced thermal sensitivity with more (P < .001) paradoxical thermal sensations (PTSs), and hyperalgesia with lower pain thresholds to mechanical (P < .001) stimuli at both the upper and lower limbs and cold (P = .005) stimulation at the lower limb. Using a parallel conditioned pain modulation paradigm, the cEDS group showed significantly smaller antinociceptive responses (P-value .005-.046) suggestive of impaired endogenous pain modulation. In conclusion, individuals with cEDS report chronic pain and worse health-related quality of life and present altered somatosensory perception. This study is the first to systematically investigate pain and somatosensory characteristics in a genetically defined HCTD and provides interesting insights into the possible role of the ECM in the development and persistence of pain. PERSPECTIVE: Chronic pain compromises the quality of life in individuals with cEDS. Moreover, an altered somatosensory perception was found in the cEDS group with hypoesthesia for vibration stimuli, more PTSs, hyperalgesia for pressure stimuli, and impaired pain modulation., (Copyright © 2023 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

The classification of non-specific chronic low back pain (CLBP) according to multidimensional data could guide clinical management; yet recent systematic reviews show this has not been attempted. This was a prospective cross-sectional study of participants with CLBP (n = 21) and age-, sex- and height-matched pain-free controls (n = 21). Nervous system, lumbar spinal tissue and psychosocial factors were collected. Dimensionality reduction was followed by fuzzy c-means clustering to determine sub-groups. Machine learning models (Support Vector Machine, k-Nearest Neighbour, Naïve Bayes and Random Forest) were used to determine the accuracy of classification to sub-groups. The primary analysis showed that four factors (cognitive function, depressive symptoms, general self-efficacy and anxiety symptoms) and two clusters (normal versus impaired psychosocial profiles) optimally classified participants. The error rates in classification models ranged from 4.2 to 14.2% when only CLBP patients were considered and increased to 24.2 to 37.5% when pain-free controls were added. This data-driven pilot study classified participants with CLBP into sub-groups, primarily based on psychosocial factors. This contributes to the literature as it was the first study to evaluate data-driven machine learning CLBP classification based on nervous system, lumbar spinal tissue and psychosocial factors. Future studies with larger sample sizes should validate these findings., (© 2023. Springer Nature Limited.)

Objective: Although there has been increasing interest in the role of systemic cytokines in chronic spinal pain (CSP), the evidence on their potential contribution is still unclear. Therefore, the current study systematically reviewed the evidence on systemic cytokine level differences between people with CSP compared to healthy controls (HCs) and the potential associations with pain severity., Methods: An electronic search was conducted on PubMed, Web of Science and Embase. All included studies were classified as observational studies, exploring the comparison between a CSP group and a HC group, and the association between systemic cytokine levels and pain severity., Results: Nine articles were included with a total sample of 400 CSP patients suffering from chronic whiplash associated disorder (CWAD) or chronic low back pain (CLBP). In CLBP, moderate evidence was found for elevated tumor necrosis factor (TNF) α, interleukin (IL) 6, IL-1 receptor antagonist (IL-1RA), and soluble TNF receptor (sTNF-R) type 2, for normal interferon (IFN) γ and IL-2 levels, and for reduced IL-10 levels. No association was found between pain severity and these cytokines in CLBP. In CWAD, moderate evidence was found for elevated CRP and evidence for changes in TNF-α was inconclusive. Evidence for the association between pain severity and CRP was limited, and there is probably no association between pain severity and TNF-α with limited evidence in CWAD., Conclusions: Moderate evidence indicates the presence of systemic inflammation in CSP. Evidence regarding the association between pain severity and systemic cytokines is inconclusive and limited., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Abstract: The nociceptive flexion reflex (NFR) is a spinally mediated withdrawal response and is used as an electrophysiological marker of descending modulation of spinal nociception. Chemical and pharmacological modulation of nociceptive neurotransmission at the spinal level has been evidenced by direct effects of neurotransmitters and pharmacological agents on the NFR. Largely unexplored are, however, the effects of nonpharmacological noninvasive conservative interventions on the NFR. Therefore, a systematic review and meta-analysis was performed and reported following the PRISMA guidelines to determine whether and to what extent spinal nociception measured through the assessment of the NFR is modulated by conservative therapy in patients and healthy individuals. Five electronic databases were searched to identify relevant articles. Retrieved articles were screened on eligibility using the predefined inclusion criteria. Risk of bias was investigated according to Version 2 of the Cochrane risk-of-bias assessment tool for randomized trials. The evidence synthesis for this review was conducted in accordance with the Grading of Recommendations Assessment, Development and Evaluation. Thirty-six articles were included. Meta-analyses provided low-quality evidence showing that conservative therapy decreases NFR area and NFR magnitude and moderate-quality evidence for increases in NFR latency. This suggests that conservative interventions can exert immediate central effects by activating descending inhibitory pathways to reduce spinal nociception. Such interventions may help prevent and treat chronic pain characterized by enhanced spinal nociception. Furthermore, given the responsiveness of the NFR to conservative interventions, the NFR assessment seems to be an appropriate tool in empirical evaluations of treatment strategies.PROSPERO registration number: CRD42020164495., (Copyright © 2021 International Association for the Study of Pain.)

Background: The hypermobile type of Ehlers-Danlos syndrome (hEDS) is a heritable connective tissue disorder, associated with joint hypermobility and prominent chronic pain. Because experimental pain testing in hEDS is scarce, the underlying mechanisms are still poorly understood., Objective: The present study assesses endogenous pain facilitation and pain inhibition in hEDS, using a protocol for temporal summation of pain (TSP), conditioned pain modulation (CPM) and exercise-induced hypoalgesia (EIH)., Methods: Twenty women with hEDS and 20 age-matched healthy controls participated. After evaluating thermal and mechanical pain thresholds (PPT), TSP was assessed using 10 repetitive painful pressure stimuli. CPM was provoked using pressure as the test stimulus and hand immersion in hot water (46°) as the conditioning stimulus. EIH was assessed after a submaximal cycling protocol., Results: The hEDS group demonstrated reduced PPTs and showed significantly more TSP after repeated painful stimuli than the control group. In comparison to the healthy control group, the hEDS group demonstrated significantly less EIH at the quadriceps test location. At the trapezius, EIH did not significantly differ between groups. No significant differences were found between the hEDS group and control group in the CPM response., Conclusion: The results demonstrate increased TSP in hEDS, suggesting increased central pain facilitation. EIH should be studied more extensively but may be disturbed when evaluated in the muscles that are activated during exercise. The CPM results are inconclusive and require more research., Significance: Studies regarding the mechanisms that underlie pain in hEDS are scarce, although it is the most prevalent and disabling symptom in this patient population. This study demonstrates increased temporal summation in hEDS and suggests that exercise-induced hypoalgesia may be reduced. Because exercise is a cornerstone in the multidisciplinary treatment of heritable connective tissue disorders, gaining knowledge in this field is important. Pressure stimuli were used to facilitate the international usability of the protocols, allowing for future data acquisition in large cohorts., (© 2022 European Pain Federation - EFIC®.)

Background: The biopsychosocial-spiritual model recognizes the impact of religious factors in modulating the experience of pain. Religious beliefs are factors that can influence perceptions, emotions, and behavior, all of which have important implications on health, pain experience, and treatment outcomes., Objectives: The aim of the present study was to identify if and how religious beliefs and attitudes can influence pain intensity, pain interference, pain-related beliefs and cognitions, emotions, and coping among patients with chronic musculoskeletal pain., Study Design: Systematic review., Methods: This systematic review was conducted and reported, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (PRISMA). An electronic search was conducted in 4 online databases (PubMed, Embase, Web of science, and PsychArticles) and complemented with a hand search (PROSPERO registry: CRD42020161289). Two reviewers independently performed eligibility screening, risk of bias assessment, and data extraction. The risk of bias of the included studies was assessed using the Newcastle Ottawa Scale., Results: Nine cross-sectional studies and one case-control study were included in the review. The methodological quality of the included studies ranged from low to high. The results gathered regarding the association between religiosity and pain intensity, disability, or pain interference were found to be conflicting. Limited evidence suggests that religiosity is positively associated with worse pain-related beliefs and cognitions, worse pain-related emotion, and better pain acceptance. There is insufficient data available to support the claim that religiosity is negatively associated with physical functioning and pain-related self-efficacy in people with chronic musculoskeletal pain., Limitations: The number of included studies was small, with a low level of evidence, and a possible risk of bias., Conclusion: This systematic review shows low evidence and conflicting results for the presence of associations between religiosity and different pain domains such as pain intensity, disability, and pain-related cognitions or emotions in people with chronic musculoskeletal pain.

Background: The nociceptive flexion reflex (NFR) is a spinally-mediated withdrawal reflex occurring in response to noxious stimuli and is used as an electrophysiological marker of spinal nociception. Although it is well-documented that the NFR is subject to powerful modulation of several personal factors, the effects of experimentally induced fatigue on the NFR have not yet been examined. Hence, this study aimed to characterize if and how fatigue affects spinal nociception in healthy adults., Methods: The NFR of 58 healthy people was measured prior to and following rest and two fatiguing tasks performed in randomized order. The NFR was elicited by transcutaneous electrical stimulation of the sural nerve and objectified by electromyographic recordings from the biceps femoris muscle. An isokinetic fatiguing protocol was used to induce localized muscle fatigue of the hamstrings. The modified incongruent Stroop-word task was used to provoke mental fatigue. A linear mixed model analysis was performed to assess the influence of fatigue on the NFR., Results: Low-to-moderate levels experimentally induced localized muscle and mental fatigue did not affect the NFR in healthy adults. These results suggest that descending pain inhibitory processes to dampen spinal nociception are resistant to the effects of localized muscle and mental fatigue., Conclusions: The relative robustness of the NFR to fatigue may be beneficial in both clinical and research settings where the influence of confounders complicates interpretation. Furthermore, the findings possibly help enhance our understanding on why even demanding cognitive/physical exercise-based treatment programs form effective treatment strategies for patients with chronic pain., Significance: The present study unraveled that low-to-moderate levels experimentally induced localized muscle and mental fatigue did not affect the NFR. These results suggest that descending pain inhibitory processes to dampen spinal nociception are resistant to the effects of localized muscle and mental fatigue. This relative robustness of the NFR may be beneficial in a clinical setting in which the evaluation of spinal nociception that is unaffected by clinical symptoms of fatigue may be useful (e.g. chronic fatigue syndrome, cancer-related fatigue, etc.)., (© 2021 European Pain Federation - EFIC®.)

Background: The Muscle Energy Technique (MET) is one of the treatments of choice for the management of chronic mechanical low back pain (MLBP); however, there is a paucity of evidence to justify its effectiveness., Objectives: The objectives of this review are to explore, analyze and summarize the available evidence related to the effectiveness of MET in the management of chronic MLBP., Method: The scoping review methodology was adopted based on a recommendation from the work of Arksey and O'Malley, to systematically appraise literature and map the existing evidence on the effectiveness of MET in the management of chronic MLBP. A systematic search was performed comprising of an electronic search of online databases using key search terms and subsided by a hand search to identify the existing literature on the topic which was summarized and discussed., Result: Initially 25,195 hits were identified which were screened to examine their eligibility based on predetermined inclusion criteria after removing duplicate articles. Eleven articles met the inclusion criteria and were discussed., Conclusions: Generally there exists a scarcity of published articles on the effect of MET in chronic MLBP. However, the analysis of the retrieved articles showed that the MET procedure is a favourable intervention that is safe (i.e. no adverse effects) and can be effective as a standalone treatment or in combination with other treatment strategies for patients with chronic MLBP with the potential to provide numerous physical and psychosocial benefits.

BELAVY, D. L., J. Van Oosterwijck, M. Clarkson, E. Dhondt, N. L. Mundell, C. Miller and P. J. Owen. NEUROSCI BIOBEHAV REV 21(1) XXX-XXX, 2020. Exercise training is capable of reducing pain in chronic pain syndromes, yet its mechanisms are less well established. One mechanism may be via the impact of exercise on increasing a person's pain threshold. Here we show, via meta-analysis of fifteen exercise training studies in pain syndromes that exercise training leads to increased pressure pain thresholds (low to moderate quality evidence). We also find low to moderate quality evidence exists that exercise training was more effective than non-exercise interventions, such as pain education, massage and stress management for improving pain sensitivity. Further, the effect of exercise was greater locally at the site of pain and less so at remote regions. These finding suggest that adaptations in central inhibition occur over time with exercise training and, more widely, add to the mechanistic understanding of how effective interventions can improve pain in chronic pain syndromes., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Nonspecific chronic low back pain (CLBP) is a common clinical condition that has impacts at both the individual and societal level. Pain intensity is a primary outcome used in clinical practice to quantify the severity of CLBP and the efficacy of its treatment; however, pain is a subjective experience that is impacted by a multitude of factors. Moreover, differences in effect sizes for pain intensity are not observed between common conservative treatments, such as spinal manipulative therapy, cognitive behavioral therapy, acupuncture, and exercise training. As pain science evolves, the biopsychosocial model is gaining interest in its application for CLBP management. The aim of this article is to discuss our current scientific understanding of pain and present why additional factors should be considered in conservative CLBP management. In addition to pain intensity, we recommend that clinicians should consider assessing the multidimensional nature of CLBP by including physical (disability, muscular strength and endurance, performance in activities of daily living, and body composition), psychological (kinesiophobia, fear-avoidance, pain catastrophizing, pain self-efficacy, depression, anxiety, and sleep quality), social (social functioning and work absenteeism), and health-related quality-of-life measures, depending on what is deemed relevant for each individual. This review also provides practical recommendations to clinicians for the assessment of outcomes beyond pain intensity, including information on how large a change must be for it to be considered "real" in an individual patient. This information can guide treatment selection when working with an individual with CLBP., (© 2019 World Institute of Pain.)

This systematic review analyzed available literature on functional brain alterations in low back pain (LBP) measured with electroencephalography (EEG), as until now evidence thereof was unclear. Four electronic databases were systematically searched the 10th of March 2018, resulting in 12 included studies. Studies showed a risk of bias of 37.5 to 75% using the Newcastle-Ottawa Scale for case-control studies. Limited evidence reported higher amplitudes of balance-related potentials and early components of somatosensory evoked potentials (SEP) to noxious stimuli, and altered feedback-related negativity and P300 potentials during decision-making in chronic LBP (CLBP). These findings suggest postural strategies requiring a higher cortical attention-demand, increased sensory-discriminative processing of noxious input, and altered decision-making in CLBP. However, further research is warranted as these inferences were based on single studies. Moderate evidence for unaltered amplitude of late-phase SEPs to noxious stimuli and auditory evoked potentials in LBP implies that the affective-emotional processing of stimuli might be unaffected in LBP. Furthermore, moderate evidence indicated disturbed habituation of somatosensory stimuli in LBP. Most studies examined nonspecific or mixed CLBP populations, hence EEG-quantified brain activity in (sub)acute or recurrent LBP still needs to be explored. PERSPECTIVE: This review presents an overview of the current understanding of the functional LBP brain measured with EEG. The limited evidence in current research suggests altered cortical function regarding balance control, somatosensory processing, and decision making in LBP, and highlights opportunities for future EEG-research., (Copyright © 2019. Published by Elsevier Inc.)

Background: There is a growing need to identify patient pre-treatment characteristics that could predict adherence and outcome following specific interventions., Objective: To identify predictors of adherence and outcome to outpatient multimodal rehabilitation in chronic low back pain (CLBP)., Methods: A total of 273 CLBP patients participated in an exercise-based rehabilitation program. Patients who completed ⩾ 70% of the treatment course were classified as adherent. Patients showing a post-treatment reduction of ⩾ 30% in Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) back pain intensity scores were assigned to the favorable outcome group., Results: Multivariate logistic regression revealed that higher age, higher ability to perform low-load activities, and higher degrees of kinesiophobia increased the odds to complete the rehabilitation program. By contrast, lower levels of education and back pain unrelated to poor posture increased the odds for non-adherence. Furthermore, a favorable outcome was predicted in case the cause for LBP was known, shorter symptom duration, no pain in the lower legs, no difficulties falling asleep, and short-term work absenteeism., Conclusions: Assessment and consideration of patient pre-treatment characteristics is of great importance as they may enable therapists to identify patients with a good prognosis or at risk for non-responding to outpatient multimodal rehabilitation.

Background: Differences in pain processing, muscle structure and function have been reported in patients with low back pain (LBP) with different grades of pain chronicity., Objective: The present study aims to examine differences in psychological factors, disability and subjective fatigue between subgroups of LBP based on their chronification grade., Methods: Twenty-one healthy controls (HC) and 54 LBP patients (categorized based on the grades of chronicity into recurrent LBP (RLBP), non-continuous chronic LBP (CLBP), or continuous (CLBP)) filled out a set of self-reporting questionnaires., Results: The Hospital Anxiety and Depression Scale (HADS) and Multidimensional Pain Inventory (MPI) scores indicated that anxiety, pain severity, pain interference and affective distress were lower in HC and RLBP compared to non-continuous CLBP. Anxiety scores were higher in non-continuous CLBP compared to RLBP, continuous CLBP and HC. The Pain Catastrophizing Scale for Helplessness (PSCH) was higher in non-continuous CLBP compared to HC. The Survey of Pain Attitudes (SOPA) showed no differences in adaptive and maladaptive behaviors across the groups. The Pain Disability Index (PDI) measured a higher disability in both CLBP groups compared to HC. Moreover, the Rolland Morris Disability Questionnaire (RMDQ) showed higher levels of disability in continuous CLBP compared to non-continuous CLBP, RLBP and HC. The Checklist Individual Strength (CIS) revealed that patients with non-continuous CLBP were affected to a higher extent by severe fatigue compared to continuous CLBP, RLBP and HC (subjective fatigue, concentration and physical activity). For all tests, a significance level of 0.05 was used., Conclusions: RLBP patients are more disabled than HC, but have a tendency towards a general positive psychological state of mind. Non-continuous CLBP patients would most likely present a negative psychological mindset, become more disabled and have prolonged fatigue complaints. Finally, the continuous CLBP patients are characterized by more negative attitudes and believes on pain, enhanced disability and interference of pain in their daily lives.

Background: Offset analgesia (OA) is an increasingly described phenomenon to measure endogenous pain inhibition, in which a greater decrease in pain intensity is experienced than would be predicted by the decrease in painful stimulation. The temporal filtering in this OA phenomenon differs from the spatial filtering in the commonly described conditioned pain modulation (CPM). Yet, the knowledge on the efficacy of OA in chronic pain patients is scarce, compared to CPM efficacy., Objective: This systematic review has been conducted to provide an overview of the current knowledge regarding OA, and to compare it to CPM., Study Design: A systematic review of research studies that investigated the application or mechanisms of OA., Setting: The present study took place at Ghent University and the University of Antwerp., Methods: This systematic review follows the PRISMA guidelines. The electronic databases Pubmed and Web of Science were searched in January 2015. Full text clinical reports addressing OA were included. The checklists for randomized controlled trials, case-control studies, and cohort-studies provided by the Dutch Institute for Healthcare Improvement and the Dutch Cochrane Centre were used to assess methodological quality. The articles received a level of evidence A1, A2, B, C, or D, based on study design and risk of bias. These levels were used to determine the strength of conclusion (level 1 to 4)., Results: Seventeen articles met the inclusion criteria. Sixteen studies used quantitative sensory testing to provoke OA; however, differences in protocols are present. OA can function as a non-opioid mediated assessment tool for endogenous pain inhibition, and activates brain regions such as periaqueductal gray (PAG), dorsolateral prefontral cortex, insula, medulla, pons and cerebellum, indicating strong brain derived pain modulation. The primary somatosensory cortex is, conversely, less activated during OA. OA is decreased in neuropathic patients. Nonetheless, evidence for the influence of individual factors on OA is limited. OA and CPM seem to rely on different mechanisms., Limitations: Search strategy was taken wide, wherefore a large variety of research perspectives were included., Conclusions: This systematic review displays OA as a temporal filtering mechanisms that is more brain-derived compared to the spatial assessment method CPM. There is strong evidence for reduced OA in neuropathic patients, however, evidence regarding OA in (sub)acute and central sensitization patients, and the influence of personal factors on OA is currently scarce and needs further investigation.

Background: Compelling evidence has demonstrated that impaired central pain modulation contributes to persistent pain in patients with chronic whiplash associated disorders (WAD) and fibromyalgia (FM). However, there is limited research concerning the influence of stress and relaxation on central pain modulation in patients with chronic WAD and FM., Objectives: The present study aims to investigate the effects of acute cognitive stress and relaxation on central pain modulation in chronic WAD and FM patients compared to healthy individuals., Study Design: A randomized crossover design was employed., Setting: The present study took place at the University of Brussels, the University Hospital Brussels, and the University of Antwerp., Methods: Fifty-nine participants (16 chronic WAD patients, 21 FM, 22 pain-free controls) were enrolled and subjected to various pain measurements. Temporal summation (TS) of pain and conditioned pain modulation (CPM) were evaluated. Subsequently, participants were randomly allocated to either a group that received progressive relaxation therapy or a group that performed a battery of cognitive tests (= cognitive stressor). Afterwards, all pain measurements were repeated. One week later participant groups were switched., Results: A significant difference was found between the groups in the change in TS in response to relaxation (P = 0.008) and cognitive stress (P = 0.003). TS decreased in response to relaxation and cognitive stress in chronic WAD patients and controls. In contrast, TS increased after both interventions in FM patients. CPM efficacy decreased in all 3 groups in response to relaxation (P = 0.002) and cognitive stress (P = 0.001)., Limitations: The obtained results only apply for a single session of muscle relaxation therapy and cognitive stress, whereby no conclusions can be made for effects on pain perception and modulation of chronic cognitive stress and long-term relaxation therapies., Conclusions: A single relaxation session as well as cognitive stress may have negative acute effects on pain modulation in patients with FM, while cognitive stress and relaxation did not worsen bottom-up sensitization in chronic WAD patients and healthy persons. However, endogenous pain inhibition, assessed using a CPM paradigm, worsened in chronic WAD and FM patients, as well as in healthy people following both interventions.

Objective: Pain facilitation as well as pain inhibition might be present in chronic pain patients. A decreased efficacy of pain inhibition can be measured by conditioned pain modulation (CPM). The use of the CPM paradigm in scientific research has boosted over the last few years and is recognized for its high clinical relevance in chronic pain patients. It is, however, unclear whether the presence of pain and possible modulations of pain influences the efficacy of endogenous pain inhibition, measured by CPM. This systematic literature study aimed to provide an overview of the effects of clinical pain and experimental pain induction or pain reduction on CPM in adults., Methods: A systematic literature search was conducted in the databases "Pubmed" and "Web of Science". Only full texts of original studies regarding the effect of clinical pain and experimentally induced pain and pain reduction on CPM in adults were included. The included articles were scored on methodological quality and through a CPM paradigm., Results: Twelve articles of good to moderate quality were included in this review. Some pain inhibitory medication and oral contraceptives inhibit the CPM mechanism. Removing chronic pain by surgery results in an improved CPM response. This effect is not observed when removing acute pain., Conclusion: Analgesic medication and oral contraceptives might inhibit the CPM response, whereas there is limited evidence that pain-relieving surgery improves CPM in chronic pain patients. However, the results merely suggest that decreased CPM values (as in chronic pain patients) can improve after elimination of pain., (© 2014 World Institute of Pain.)

Hyperexcitability of the central nervous system (CNS) has been suggested to play an important role in the chronic pain experienced by osteoarthritis (OA) patients. A systematic review following PRISMA guidelines was performed to evaluate the existing evidence from the literature related to the presence of central sensitization (CS) in patients with OA.Electronic databases PubMed and Web of Science were searched to identify relevant articles using pre-defined keywords regarding CS and OA. Full-text clinical reports addressing studies of CS in human adults with chronic complaints due to osteoarthritis were included and screened for methodological quality by two independent reviewers. From the 40 articles that were initially eligible for methodological quality assessment, 36 articles achieved sufficient scores and therefore were discussed. The majority of these studies were case-control studies and addressed OA of the knee joint. Different subjective and objective parameters considered manifestations of CS, which have been previously reported in other chronic pain conditions such as whiplash or rheumatoid arthritis, were established in subjects with OA pain. Overall results suggest that, although peripheral mechanisms are involved in OA pain, hypersensitivity of the CNS plays a significant role in a subgroup of subjects within this population. Although the majority of the literature provides evidence for the presence of CS in chronic OA pain, clinical identification and treatment of CS in OA is still in its infancy, and future studies with good methodological quality are necessary., (© 2014 European Pain Federation - EFIC®)

Background: The awareness is growing that central sensitization is of prime importance for the assessment and management of chronic pain, but its classification is challenging clinically since no gold standard method of assessment exists., Objectives: Designing the first set of classification criteria for the classification of central sensitization pain., Methods: A body of evidence from original research papers was used by 18 pain experts from 7 different countries to design the first classification criteria for central sensitization pain., Results: It is proposed that the classification of central sensitization pain entails 2 major steps: the exclusion of neuropathic pain and the differential classification of nociceptive versus central sensitization pain. For the former, the International Association for the Study of Pain diagnostic criteria are available for diagnosing or excluding neuropathic pain. For the latter, clinicians are advised to screen their patients for 3 major classification criteria, and use them to complete the classification algorithm for each individual patient with chronic pain. The first and obligatory criterion entails disproportionate pain, implying that the severity of pain and related reported or perceived disability are disproportionate to the nature and extent of injury or pathology (i.e., tissue damage or structural impairments). The 2 remaining criteria are 1) the presence of diffuse pain distribution, allodynia, and hyperalgesia; and 2) hypersensitivity of senses unrelated to the musculoskeletal system (defined as a score of at least 40 on the Central Sensitization Inventory)., Limitations: Although based on direct and indirect research findings, the classification algorithm requires experimental testing in future studies., Conclusion: Clinicians can use the proposed classification algorithm for differentiating neuropathic, nociceptive, and central sensitization pain.

Chronic spinal pain (CSP) is a severely disabling disorder, including nontraumatic chronic low back and neck pain, failed back surgery, and chronic whiplash-associated disorders. Much of the current therapy is focused on input mechanisms (treating peripheral elements such as muscles and joints) and output mechanisms (addressing motor control), while there is less attention to processing (central) mechanisms. In addition to the compelling evidence for impaired motor control of spinal muscles in patients with CSP, there is increasing evidence that central mechanisms (ie, hyperexcitability of the central nervous system and brain abnormalities) play a role in CSP. Hence, treatments for CSP should address not only peripheral dysfunctions but also the brain. Therefore, a modern neuroscience approach, comprising therapeutic pain neuroscience education followed by cognition-targeted motor control training, is proposed. This perspective article explains why and how such an approach to CSP can be applied in physical therapist practice.

Objectives: There is evidence that education on pain physiology can have positive effects on pain, disability, and catastrophization in patients with chronic musculoskeletal pain disorders. A double-blind randomized controlled trial (RCT) was performed to examine whether intensive pain physiology education is also effective in fibromyalgia (FM) patients, and whether it is able to influence the impaired endogenous pain inhibition of these patients., Methods: Thirty FM patients were randomly allocated to either the experimental (receiving pain physiology education) or the control group (receiving pacing self-management education). The primary outcome was the efficacy of the pain inhibitory mechanisms, which was evaluated by spatially accumulating thermal nociceptive stimuli. Secondary outcome measures included pressure pain threshold measurements and questionnaires assessing pain cognitions, behavior, and health status. Assessments were performed at baseline, 2 weeks, and 3 months follow-up. Repeated measures ANOVAS were used to reveal possible therapy effects and effect sizes were calculated., Results: After the intervention the experimental group had improved knowledge of pain neurophysiology (P<0.001). Patients from this group worried less about their pain in the short term (P=0.004). Long-term improvements in physical functioning (P=0.046), vitality (P=0.047), mental health (P<0.001), and general health perceptions (P<0.001) were observed. In addition, the intervention group reported lower pain scores and showed improved endogenous pain inhibition (P=0.041) compared with the control group., Discussion: These results suggest that FM patients are able to understand and remember the complex material about pain physiology. Pain physiology education seems to be a useful component in the treatment of FM patients as it improves health status and endogenous pain inhibition in the long term.

Background: Exercise is an effective treatment for various chronic pain disorders, including fibromyalgia, chronic neck pain, osteoarthritis, rheumatoid arthritis, and chronic low back pain. Although the clinical benefits of exercise therapy in these populations are well established (i.e. evidence based), it is currently unclear whether exercise has positive effects on the processes involved in chronic pain (e.g. central pain modulation)., Objectives: Reviewing the available evidence addressing the effects of exercise on central pain modulation in patients with chronic pain., Methods: Narrative review., Results: Exercise activates endogenous analgesia in healthy individuals. The increased pain threshold following exercise is due to the release of endogenous opioids and activation of (supra)spinal nociceptive inhibitory mechanisms orchestrated by the brain. Exercise triggers the release of beta-endorphins from the pituitary (peripherally) and the hypothalamus (centrally), which in turn enables analgesic effects by activating μ-opioid receptors peripherally and centrally, respectively. The hypothalamus, through its projections on the periaqueductal grey, has the capacity to activate descending nociceptive inhibitory mechanisms. However, several groups have shown dysfunctioning of endogenous analgesia in response to exercise in patients with chronic pain. Muscle contractions activate generalized endogenous analgesia in healthy, pain-free humans and patients with either osteoarthritis or rheumatoid arthritis, but result in increased generalised pain sensitivity in fibromyalgia patients. In patients having local muscular pain (e.g. shoulder myalgia), exercising non-painful muscles activates generalized endogenous analgesia. However, exercising painful muscles does not change pain sensitivity either in the exercising muscle or at distant locations., Limitations: The reviewed studies examined acute effects of exercise rather than long-term effects of exercise therapy., Conclusions: A dysfunctional response of patients with chronic pain and aberrations in central pain modulation to exercise has been shown, indicating that exercise therapy should be individually tailored with emphasis on prevention of symptom flares. The paper discusses the translation of these findings to rehabilitation practice together with future research avenues.

Central sensitization provides an evidence-based explanation for many cases of 'unexplained' chronic musculoskeletal pain. Prior to commencing rehabilitation in such cases, it is crucial to change maladaptive illness perceptions, to alter maladaptive pain cognitions and to reconceptualise pain. This can be accomplished by patient education about central sensitization and its role in chronic pain, a strategy known as pain physiology education. Pain physiology education is indicated when: 1) the clinical picture is characterized and dominated by central sensitization; and 2) maladaptive illness perceptions are present. Both are prerequisites for commencing pain physiology education. Face-to-face sessions of pain physiology education, in conjunction with written educational material, are effective for changing pain cognitions and improving health status in patients with various chronic musculoskeletal pain disorders. These include patients with chronic low back pain, chronic whiplash, fibromyalgia and chronic fatigue syndrome. After biopsychosocial assessment pain physiology education comprises of a first face-to-face session explaining basic pain physiology and contrasting acute nociception versus chronic pain (Session 1). Written information about pain physiology should be provided as homework in between session 1 and 2. The second session can be used to correct misunderstandings, and to facilitate the transition from knowledge to adaptive pain coping during daily life. Pain physiology education is a continuous process initiated during the educational sessions and continued within both the active treatment and during the longer term rehabilitation program., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background and objectives It has been suggested that sensitization of the central nervous system plays an important role in the development and maintenance of chronic (pain) complaints experienced by whiplash patients. According to the PRISMA guidelines, a systematic review was performed to screen and evaluate the existing clinical evidence for the presence of central sensitization in chronic whiplash. Databases and data treatment Predefined keywords regarding central sensitization and chronic whiplash were combined in electronic search engines Pub Med and Web of Science. Full text clinical reports addressing studies of central sensitization in human adults with chronic complaints due to a whiplash trauma were included and reviewed on methodological quality by two independent reviewers. Results From the 99 articles that were identified, 24 met the inclusion criteria, and 22 articles achieved sufficient scores on methodological quality and were discussed. These studies evaluated the sensitivity to different types of stimuli (mechanical, thermal, electrical). Findings suggest that although different central mechanisms seem to be involved in sustaining the pain complaints in whiplash patients, hypersensitivity of the central nervous system plays a significant role. Persistent pain complaints, local and widespread hyperalgesia, referred pain and (thoracic) allodynia, decreased spinal reflex thresholds, inefficient diffuse noxious inhibitory controls activation and enhanced temporal summation of pain were established in chronic whiplash patients. Conclusions Although the majority of the literature provides evidence for the presence of central sensitization in chronic whiplash, underlying mechanisms are still unclear and future studies with good methodological quality are necessary. In addition, international guidelines for the definition, clinical recognition, assessment and treatment of central sensitization are warranted. [ABSTRACT FROM AUTHOR]

AbstractPurposeMethodResultsConclusion\nIMPLICATIONS FOR REHABILITATIONThis paper aims to understand the distinctive biopsychosocial aspects and patient perspectives on chronic low back pain in Lebanon, an Arab country with a unique and rich cultural heritage.Qualitative, semi-structured interviews with 12 Lebanese patients purposefully sampled from various governorates. The interviews included participants from different geographic areas and religions. The data underwent analysis through an inductive thematic approach guided by a bounded relativist ontology, a subjectivist epistemology, and a descriptive phenomenological framework. The coding process was managed by computer-assisted qualitative data analysis software (QSR NVivo version 12.0).The researchers identified and constructed two themes: (1) Chronic low back pain: understanding the impact, coping strategies, and communication patterns in lived experiences within the Lebanese context. This theme sheds light on the complexities of pain management and societal influences in Lebanon. (2) Explanatory model of patients living with chronic low back pain in Lebanon. This theme allowed an exploration of the multifaceted narratives of chronic low back pain.This study found that Lebanese individuals attribute chronic low back pain to biomedical factors despite some recognizing psychosocial elements. It emphasizes the need to educate patients on the biopsychosocial model, facilitate better care, and dispel misconceptions.The exploration of patients’ pain perception may provide an opportunity to better develop and design culturally sensitive pain neuroscience education material for Arab-speaking and Lebanese physical therapists.The rehabilitation process should incorporate a balanced biopsychosocial approach, addressing both physical and psychosocial elements of pain, to provide more effective care and outcomes for Lebanese patients who predominantly attribute chronic low back pain to biomedical factors.Lebanese healthcare professionals need to improve communication with Lebanese patients regarding the nature of chronic low back pain, using clear communication to help dispel misconceptions and enhance rehabilitation outcomes.The exploration of patients’ pain perception may provide an opportunity to better develop and design culturally sensitive pain neuroscience education material for Arab-speaking and Lebanese physical therapists.The rehabilitation process should incorporate a balanced biopsychosocial approach, addressing both physical and psychosocial elements of pain, to provide more effective care and outcomes for Lebanese patients who predominantly attribute chronic low back pain to biomedical factors.Lebanese healthcare professionals need to improve communication with Lebanese patients regarding the nature of chronic low back pain, using clear communication to help dispel misconceptions and enhance rehabilitation outcomes. [ABSTRACT FROM AUTHOR]