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Conservative management of lumbar radiculopathy (LR) is the first treatment option. To date, systematic reviews and clinical practice guidelines have not considered the most appropriate timing of management. This study aimed to establish consensus on effective conservative treatment modalities across different stages (i.e., acute, sub-acute, or chronic) of LR. Through an iterative multistage Delphi process, experts rated agreement with proposed treatment modalities across stages of LR and could suggest additional treatment modalities. The agreement was measured using a 5-point Likert scale. Descriptive statistics were used to measure agreement (median, interquartile ranges, and percentage of agreement). Consensus criteria were defined a priori for each round. Fourteen panelists produced a consensus list of effective treatment modalities across stages of LR. Acute stage management should focus on providing patients with information about the condition including pain education, individualized physical activity, and directional preference exercises, supported with NSAIDs. In the sub-acute stage, strength training and neurodynamic mobilization could be added and transforaminal/epidural injections considered. In the chronic stage, spinal manipulative therapy, specific exercise, and function-specific physical training should be combined with individualized vocational, ergonomic and postural advice. Experts agree effectiveness of interventions differs through the evolution of LR. To date clinical guideline for conservative management of lumbar radiculopathy do not consider the evolution of the condition. Acute stage management of lumbar radiculopathy should focus on providing information about the condition and support individualized physical activity with pain medication. Sub-acute management should add neurodynamic mobilization to strength training, while transforaminal and/or epidural injections could be considered. Chronic stage management should consider spinal manipulative therapy and focus on restoring personalized functional capacity. [ABSTRACT FROM AUTHOR]

Background and Aims According to existing literature, musicians are at risk of experiencing a range of painful musculoskeletal conditions. Recently, a novel digital technology was developed to investigate pain location and pain extent. The aim of this study was to describe pain location and pain extent in musicians using a digital method for pain drawing ( PD) analysis. Additionally, the association between PD variables and clinical features were explored in musicians with pain. Methods One hundred and fifty-eight musicians (90 women and 68 men; aged 22.4 ± 3.6 years) were recruited from Swiss and U.K. conservatories. Participants were asked to complete a survey including both background musical information and clinical features, the Quick DASH ( QD) questionnaire, and the digital PDs. Results Of the 158 participants, 126 musicians (79.7%) reported having pain, with higher prevalence in the areas of the neck and shoulders, the lower back, and the right arm. The mean percentage of pain extent was 3.1% ± 6.5%. The mean QD score was higher for musicians with pain than for those without pain. Additionally, the results indicated a positive correlation between the QD score and pain extent, and there were significant correlations between age and pain intensity, as well as between pain extent and pain intensity. Conclusions The high prevalence of pain among musicians has been confirmed using a digital technique for PD acquisition and analysis. In addition, positive correlations between pain extent and upper limb disability have been demonstrated. Our findings highlight the need for effective prevention and treatment strategies for musicians. [ABSTRACT FROM AUTHOR]

The article reports on research which was conducted to investigate the effect strength and endurance training on muscle fiber membrane properties and discharge rates of low-threshold motor units of the vasti muscles during fatiguing contractions. Researchers evaluated 25 sedentary healthy men who were randomly assigned to one of three groups: strength training, endurance training, or a control group. They found that short-term strength and endurance training induces alterations of the electrophysiological membrane properties of the muscle fiber and that endurance training lowers the rate of decline of motor unit conduction velocity during sustained contractions more than strength training.

Sensitization mechanisms are thought to play a role in the perception of pain in people with cluster headache. No study has investigated the relation between the spatial extent of pain in cluster headache and measures of sensitization or other clinical features. Our aim was to investigate if the size of the painful area in people with cluster headache relates to widespread pressure sensitivity, headache features, and psychological outcomes. Forty men with episodic cluster headache reported their symptoms on a digital body chart and pain extent was calculated. Pressure pain thresholds were assessed locally over the temporalis muscle and the C5-C6 joint and at a remote site over the tibialis anterior to assess widespread pressure sensitivity. Clinical features of headache attacks, and anxiety/depressive levels were also assessed. Patients were assessed during a period of remission 6 months after their last pain attack and after treatment discontinuation. Thirty-two (80%) and thirty (75%) patients reported their headaches in the orbital and the frontal areas, respectively. No significant associations (rho values ranging from −0.228 to 0.187, P values ranging from 0.157 to 0.861) were found between pain extent and pressure pain thresholds in trigeminal, extra-trigeminal, and distant pain-free areas, headache clinical features, and anxiety and depressive levels. Pain extent in the trigemino-cervical area was not related to the degree of pressure pain sensitivity or headache features in men with episodic cluster headache during a period of remission. [ABSTRACT FROM AUTHOR]

Background: Neuropathic pain (NP) is common in patients presenting with low back related leg pain. Accurate diagnosis of NP is fundamental to ensure appropriate intervention. In the absence of a clear gold standard, expert opinion provides a useful methodology to progress research and clinical practice. The aim of this study was to achieve expert consensus on a list of clinical indicators to identify NP in low back related leg pain.Methods: A modified Delphi method consisting of three rounds was designed in accordance with the Conducting and Reporting Delphi Studies recommendations. Recruitment involved contacting experts directly and through expressions of interest on social media. Experts were identified using pre-defined eligibility criteria. Priori consensus criteria were defined for each round through descriptive statistics. Following completion of round 3 a list of clinical indicators that achieved consensus were generated.Results: Thirty-eight participants were recruited across 11 countries. Thirty-five participants completed round 1 (92.1%), 32 (84.2%) round 2 and 30 (78.9%) round 3. Round 1 identified consensus (Kendall's W coefficient of concordance 0.456; p < 0.001) for 10 clinical indicators out of the original 14, and 9 additional indicators were added to round 2 following content analysis of qualitative data. Round 2 identified consensus (Kendall's W coefficient of concordance 0.749; p < 0.001) for 10 clinical indicators out of 19, and 1 additional indicator was added to round 3. Round 3 identified consensus for 8 indicators (Kendall's W coefficient of concordance 0.648; p < 0.001). Following completion of the third round, an expert derived consensus list of 8 items was generated. Two indicators; pain variously described a burning, electric shock like and/or shooting into leg and pain in association with other neurological symptoms (e.g. pins and needles, numbness, weakness), were found to have complete agreement amongst expert participants.Conclusions: Good agreement was found for the consensus derived list of 8 clinical indicators to identify NP in low back related leg pain. This list of indicators provide some indication of the criteria upon which clinicians can identify a NP component to low back related leg pain; further research is needed for stronger recommendations to be made. [ABSTRACT FROM AUTHOR]

Introduction: When performing an exercise or a functional test, pain that is evoked by movement or muscle contraction could be a stronger stimulus for changing how individuals move compared to tonic pain. We investigated whether the decrease in muscle force production is larger when experimentally‐induced knee pain is directly associated to the torque produced (movement‐evoked) compared to a constant painful stimulation (tonic). Methods: Twenty‐one participants performed three isometric knee extension maximal voluntary contractions without pain (baseline), during pain, and after pain. Knee pain was induced using sinusoidal electrical stimuli at 10 Hz over the infrapatellar fat pad, applied continuously or modulated proportionally to the knee extension torque. Peak torque and contraction duration were averaged across repetitions and normalized to baseline. Results: During tonic pain, participants reported lower pain intensity during the contraction than at rest (p < 0.001), whereas pain intensity increased with contraction during movement‐evoked pain (p < 0.001). Knee extension torque decreased during both pain conditions (p < 0.001), but a larger reduction was observed during movement‐evoked compared to tonic pain (p < 0.001). Participants produced torque for longer during tonic compared to movement‐evoked pain (p = 0.005). Conclusion: Our results indicate that movement‐evoked pain was a more potent stimulus to reduce knee extension torque than tonic pain. The longer contraction time observed during tonic pain may be a result of a lower perceived pain intensity during muscle contraction. Overall, our results suggest different motor adaptation to tonic and movement‐evoked pain and support the notion that motor adaptation to pain is a purposeful strategy to limit pain. This mechanistic evidence suggests that individuals experiencing prevalently tonic or movement‐evoked pain may exhibit different motor adaptations, which may be important for exercise prescription. [ABSTRACT FROM AUTHOR]

Supplemental digital content is available in the text. Purpose: Motor unit conduction velocity (MUCV) represents the propagation velocity of action potentials along the muscle fibers innervated by individual motor neurons and indirectly reflects the electrophysiological properties of the sarcolemma. In this study, we investigated the effect of a 4-wk strength training intervention on the peripheral properties (MUCV and motor unit action potential amplitude, RMSMU) of populations of longitudinally tracked motor units (MU). Methods: The adjustments exhibited by 12 individuals who participated in the training (INT) were compared with 12 controls (CON). Strength training involved ballistic (4 × 10) and sustained (3 × 10) isometric ankle dorsiflexions. Measurement sessions involved the recordings of maximal voluntary isometric force and submaximal isometric ramp contractions, whereas high-density surface EMG was recorded from the tibialis anterior. High-density surface EMG signals were decomposed into individual MU discharge timings, and MU was tracked across the intervention. Results: Maximal voluntary isometric force (+14.1%, P = 0.003) and average MUCV (+3.0%, P = 0.028) increased in the INT group, whereas normalized MU recruitment threshold (RT) decreased (−14.9%, P = 0.001). The slope (rate of change) of the regression between MUCV and MU RT increased only in the INT group (+32.6%, P = 0.028), indicating a progressive greater increase in MUCV for higher-threshold MU. The intercept (initial value) of MUCV did not change after the intervention (P = 0.568). The association between RMSMU and MU RT was not altered by the training. Conclusion: The increase in the rate of change in MUCV as a function of MU RT, but not the initial value of MUCV, suggests that short-term strength training elicits specific adaptations in the electrophysiological properties of the muscle fiber membrane in high-threshold MU. [ABSTRACT FROM AUTHOR]

Objective Previous neuroimaging studies have shown that patients with chronic pain display altered functional connectivity across distributed brain areas involved in the processing of nociceptive stimuli. The aim of the present study was to investigate how pain chronification modulates whole-brain functional connectivity during evoked clinical and tonic pain. Methods Patients with osteoarthritis of the hip (n  = 87) were classified into 3 stages of pain chronification (Grades I–III, Mainz Pain Staging System). Electroencephalograms were recorded during 3 conditions: baseline, evoked clinical hip pain, and tonic cold pain (cold pressor test). The effects of both factors (recording condition and pain chronification stage) on the phase-lag index, as a measure of neuronal connectivity, were examined for different frequency bands. Results In women, we found increasing functional connectivity in the low-frequency range (delta, 0.5–4 Hz) across pain chronification stages during evoked clinical hip pain and tonic cold pain stimulation. In men, elevated functional connectivity in the delta frequency range was observed in only the tonic cold pain condition. Conclusions Across pain chronification stages, we found that widespread cortical networks increase their synchronization of delta oscillations in response to clinical and experimental nociceptive stimuli. In view of previous studies relating delta oscillations to salience detection and other basic motivational processes, our results hint at these mechanisms playing an important role in pain chronification, mainly in women. [ABSTRACT FROM AUTHOR]

Objective To compare the effects of dry needling or manual pressure release on an active trigger point in the upper trapezius on craniocervical flexion test performance, pressure pain thresholds, and cervical range of motion in chronic neck pain. Design A parallel randomized clinical trial. Setting Physical therapy service. Subjects Individuals with chronic neck pain. Methods Subjects were randomized to receive dry needling (n = 25) or manual trigger point pressure release (n = 25) on upper trapezius active trigger points. Surface electromyography from the upper trapezius, splenius capitis, sternocleidomastoid, and scalene muscles during performance of the craniocervical flexion test was assessed before and immediately after the intervention as the primary outcome. Neck pain intensity, range of motion, and pressure pain thresholds were the secondary outcomes. Results A decrease in sternocleidomastoid activity at all stages of the craniocervical flexion test (time effect, P  < 0.001) was found in both groups after the interventions, with no significant between-group difference. Pressure pain thresholds measured over the cervical spine and second metacarpal increased after dry needling when compared with manual trigger point pressure release (P  < 0.05). Pain intensity decreased immediately after both treatments with moderate to large effect sizes, whereas cervical range of motion increased for both groups but with small effect sizes. Conclusion A single session of dry needling or manual pressure release over upper trapezius active trigger points promotes limited effects on muscle performance during the craniocervical flexion test, pressure pain thresholds, and cervical range of motion in patients with chronic neck pain. [ABSTRACT FROM AUTHOR]

Background Several factors such as neck pain intensity, disability, anxiety, depression, female sex, or a previous history of headache are associated with post-whiplash headache. However, the possible role of psychosocial factors contributing to the presence of headache or worsening of headache after a whiplash trauma remains unclear. To address this gap in knowledge, there is the need to assess psychosocial factors concerning headache shortly after a whiplash injury. Objective To evaluate psychological features, pain and disability in people with acute whiplash associated disorders (WAD) and compare these features between those with and without headache. Design Case-control study. Setting A secondary care traumatology center. Methods Forty-seven people with acute WAD were recruited; 28 with headache, and 19 without. All participants completed self-reported questionnaires including Visual Analogue Scale (VAS) for neck pain intensity, the Neck Disability Index (NDI), Pain Catastrophizing Scale (PCS), Tampa Scale Kinesiophobia-11 (TSK-11), and State-Trait Anxiety Inventory. Results Neck pain intensity (P  < .001), neck disability (P  < 0.001), pain catastrophizing (P  < .001), kinesiophobia (P  < .001), and anxiety state (P  = .007) and trait (P  = .05) were higher in those with headache when compared to those without. In addition, high levels of neck pain (P  = .025), moderate levels of neck disability (P  < .001), moderate levels of pain catastrophizing (P  = .015), and moderate (P  = .002) and severe (P  = .016) levels of kinesiophobia were related to the presence of headache. Conclusions The level of neck pain intensity and disability, kinesiophobia, catastrophizing, and anxiety were all greater in people with acute WAD who presented with a headache compared to those without headache. [ABSTRACT FROM AUTHOR]

Background. Little is known about the effectiveness of exercise programs after decompression surgery for subacromial impingement syndrome. For patients with difficulty returning to usual activities, special efforts may be needed to improve shoulder function. Objective. The purpose of this study was to evaluate the effectiveness at 3 and 12 months of a standardized physical therapy exercise intervention compared with usual care in patients with difficulty returning to usual activities after subacromial decompression surgery. Design. A multicenter randomized controlled trial was conducted. Setting. The study was conducted in 6 public departments of orthopedic surgery, 2 departments of occupational medicine, and 2 physical therapy training centers in Central Denmark Region. Patients. One hundred twenty-six patients reporting difficulty returning to usual activities at the postoperative clinical follow-up 8 to 12 weeks after subacromial decompression surgery participated. Intervention. A standardized exercise program consisting of physical therapist-supervised individual training sessions and home training was used. Outcome Measures. The primary outcome measure was the Oxford Shoulder Score. Secondary outcome measures were the Constant Score and the Fear-Avoidance Beliefs Questionnaire. Results. At 3 and 12 months, follow-up data were obtained for 92% and 83% of the patients, respectively. Intention-to-treat analyses suggested a between-group difference on the Oxford Shoulder Score favoring the exercise group at 3 months, with an adjusted mean difference of 2.0 (95% confidence interval = -0.5, 4.6), and at 12 months, with an adjusted mean difference of 5.8 (95% confidence interval=2.8, 8.9). Significantly larger improvements for the exercise group were observed for most secondary and supplementary outcome measures. Limitations. The nature of the exercise intervention did not allow blinding of patients and care providers. Conclusion. The standardized physical therapy exercise intervention resulted in statistically significant and clinically relevant improvement in shoulder pain and function at 12 months compared with usual care. [ABSTRACT FROM AUTHOR]

Objective: This explorative study investigates the moderating effect of sex and baseline pain characteristics on the effectiveness of preoperative pain neuroscience education (PNE) plus knee joint mobilization versus biomedical education plus knee joint mobilization in patients who have knee osteoarthritis and are scheduled to undergo total knee arthroplasty (TKA). Methods: After baseline assessment of self-reported questionnaires (pain intensity, disability, symptoms of central sensitization and pain cognitions) and quantitative sensory testing, 44 participants with knee osteoarthritis were randomized into the PNE plus knee joint mobilization or biomedical education plus knee joint mobilization group. The questionnaires were retaken directly after and 1 month after 4 sessions of treatment and at 3 months after surgery. Based on baseline quantitative sensory testing results, the sample was subdivided into a high (showing high experimental pain levels and low pressure pain thresholds) and low pain cluster using principal components analysis and cluster analysis. Therapy effects over time were evaluated using 3-way analysis of variance, with time as the within factor and treatment, sex, and baseline pain cluster as between factors. Results: Women benefited significantly more from the PNE intervention compared with the control intervention in terms of self-reported symptoms of central sensitization. For both pain clusters, differences in therapeutic effects concerning pain intensity and pain cognitions were found, with higher superiority of the PNE intervention in the high-pain cluster subgroup compared with the low-pain cluster. Conclusion: Based on these explorative analyses, it can be concluded that sex and preoperative pain measures may influence the effectiveness of preoperative PNE for some specific outcome measures in people scheduled to undergo TKA. Impact: Although further research on this topic is needed, the potential influence of sex and preoperative pain measures on the effectiveness of preoperative PNE should be considered when implementing this intervention in people undergoing TKA. [ABSTRACT FROM AUTHOR]

• A single session of dry needling of the obliquus capitis inferior reduces cervical joint position error in people with neck pain. • Dry needling of the obliquus capitis inferior does not have an effect on cervical movement sense or postural stability. • Dry needling of the obliquus capitis inferior increases upper cervical range of motion measured with the flexion rotation test. Impairments of sensorimotor control relating to head and eye movement control and postural stability are often present in people with neck pain. The upper cervical spine and particularly the obliquus capitis inferior (OCI) play an important proprioceptive role; and its impairment may alter cervical sensorimotor control. Dry needling (DN) is a valid technique to target the OCI. To investigate if a single DN session of the OCI muscle improves head and eye movement control-related outcomes, postural stability, and cervical mobility in people with neck pain. Forty people with neck pain were randomly assigned to receive a single session of DN or sham needling of the OCI. Cervical joint position error (JPE), cervical movement sense, standing balance and oculomotor control were examined at baseline, immediately post-intervention, and at one-week follow-up. Active cervical rotation range of motion and the flexion rotation test were used to examine the global and upper cervical rotation mobility, respectively. Linear mixed-models revealed that the DN group showed a decrease of JPE immediately post-intervention compared to the sham group (mean difference [MD]= -0.93°; 95% confidence interval [CI]: -1.85, -0.02) which was maintained at one-week follow-up (MD= -1.64°; 95%CI: -2.85, -0.43). No effects on standing balance or cervical movement sense were observed in both groups. Upper cervical mobility showed an increase immediately after DN compared to the sham group (MD= 5.14°; 95%CI: 0.77, 9.75) which remained stable at one-week follow-up (MD= 6.98°; 95%CI: 1.31, 12.40). Both group showed an immediate increase in global cervical mobility (MD= -0.14°; 95%CI: -5.29, 4.89). The results from the current study suggest that a single session of DN of the OCI reduces JPE deficits and increases upper cervical mobility in patients with neck pain. Future trials should examine if the addition of this technique to sensorimotor control training add further benefits in the management of neck pain. [ABSTRACT FROM AUTHOR]

Purpose: To investigate whether people with chronic low back pain (LBP) show dysfunctional exercise‐induced hypoalgesia (EIH) in response to repeated contractions of their back muscles during a lifting task. Methods: In this cross‐sectional observational study conducted on asymptomatic participants (n = 18) and participants with chronic LBP (n = 21), quantitative sensory testing (QST) was applied extensively over the lumbar region and a remote area before and after a repeated task that involved lifting a 5‐kg box for ~7 minutes. QST included pressure pain thresholds (PPTs), thermal detection, pain thresholds, and measures of temporal summation. Topographical maps of the percentage change in PPT detected at 16 locations over the lumbar region were generated to explore regional differences and compared between groups. Results: Mean (standard deviation) PPTs measured from 16 sites over the lower back changed significantly in asymptomatic participants (+29.78 kPa [41.4]) following task completion, indicative of EIH, whereas no significant change was observed for the low back pain (LBP) group (−14.87 kPa [61.2]). No changes were detected at the remote site for either group. No changes were revealed for the thermal tests. Temporal summation data revealed decreasing pain sensitivity as the test progressed, but the test response did not change after the exercise for either group. Conclusion(s): Unlike asymptomatic individuals, participants with LBP lacked EIH over the lumbar erector spinae muscles following repeated lifting. Although these results should be considered in relation to the study limitations, particularly the absence of a control group, the findings support impaired EIH in patients with LBP. [ABSTRACT FROM AUTHOR]

Objective: To assess the influence of clinical, psychological, and psychophysical variables on long‐term clinical outcomes after the application of either physical therapy or surgery in women presenting with carpal tunnel syndrome (CTS). Methods: A secondary analysis of a randomized trial investigating the efficacy of manual therapy including desensitization maneuvers of the central nervous system against surgery in 120 women with CTS was performed. Clinical outcomes including pain intensity, function, or symptom severity were assessed at 6 and 12 months post‐intervention. Participants completed at baseline several clinical (pain intensity, function, and symptom severity), psychological (depression), and psychophysical (pressure pain thresholds and pain extent) variables, which were included as predictors. Multiple regression analyses were conducted to assess the relationship between baseline variables and clinical outcomes at 6 and 12 months post‐intervention. Results: The regression models indicated that higher scores of each clinical outcome (ie, intensity of pain or symptom severity) at baseline predicted better outcomes at 6 and 12 months post‐intervention (from 15% to 65% of variance) in both groups. Lower pressure pain thresholds over the carpal tunnel at baseline predicted poorer clinical outcomes at 6 and 12 months post‐intervention (from 5% to 20% of variance) in the physical therapy group, whereas higher depressive symptoms at baseline contributed to poorer outcomes at 6 and 12 months post‐intervention (from 5% to 15% of the variance) within the surgery group. Conclusion: This study found that baseline localized pressure pain sensitivity and depression were predictive of long‐term clinical outcomes in women with CTS following physical therapy or surgery, respectively. [ABSTRACT FROM AUTHOR]

Objective: To determine the efficacy of suboccipital inhibitory techniques in people with migraine compared with a control treatment based on myofascial trigger point (MTrP) therapy and stretching. Design: A randomized, double-blind controlled pilot trial was conducted. Settings/Location: University research laboratory. Subjects: Forty-six adults diagnosed with migraine with over 6 months duration. Interventions: Participants were randomized to receive either combined MTrP therapy and stretching (control group) or the control treatment plus suboccipital soft tissue inhibition (experimental group). Treatment was applied on four occasions over 8 weeks (one every 15 days), with a duration of 30 minutes per session in the experimental group and 20 min in the control group. Outcome measures: The impact of headache was assessed with the Headache Impact Test (HIT-6), disability by the migraine disability assessment (MIDAS), and quality of life by the Short Form Health Survey (SF-36). Both groups were assessed at baseline and 1 week immediately after the end of treatment. Results: The amount of change of the HIT-6 score and MIDAS scores were significantly different between groups (p < 0.05), although the SF-36 scores were not. The change in the HIT-6 score and MIDAS scores was greater in the experimental group. Both groups showed a reduction on the HIT-6 score (p < 0.001), MIDAS scores (p < 0.05), and SF-36 physical subscale, whereas the SF-36 mental subscale improved only in the experimental group (p < 0.001). Conclusion: Soft tissue techniques based on MTrP therapy and stretching were helpful for improving certain aspects of migraine, such as the impact and disability caused by the headache, and the frequency and intensity of headache; however, when combined with suboccipital soft tissue inhibition, the treatment effect was larger. [ABSTRACT FROM AUTHOR]

Background. Expanded distribution of pain is considered a sign of central sensitization (CS). The relationship between recording of symptoms and CS in people with knee osteoarthritis (OA) has been poorly investigated. Objective. The aim of this study was to examine whether the area of pain assessed using pain drawings relates to CS and clinical symptoms in people with knee OA. Design. This was a cross-sectional study. Methods. Fifty-three people with knee OA scheduled to undergo primary total knee arthroplasty were studied. All participants completed pain drawings using a novel digital device, completed self-administration questionnaires, and were assessed by quantitative sensory testing. Pain frequency maps were generated separately for women and men. Spearman correlation coefficients were computed to reveal possible correlations between the area of pain and quantitative sensory testing and clinical symptoms. Results. Pain frequency maps revealed enlarged areas of pain, especially in women. Enlarged areas of pain were associated with higher knee pain severity (rs=.325, P<.05) and stiffness (rs=.341, P<.05), lower pressure pain thresholds at the knee (rs= -.306, P<.05) and epicondyle (rs=-.308, P<05), and higher scores with the Central Sensitization Inventory (rs=.456, P<.01). No significant associations were observed between the area of pain and the remaining clinical symptoms and measures of CS. Limitations. Firm conclusions about the predictive role of pain drawings cannot be drawn. Further evaluation of the reliability and validity of pain area extracted from pain drawings in people with knee OA is needed. Conclusion. Expanded distribution of pain was correlated with some measures of CS in individuals with knee OA. Pain drawings may constitute an easy way for the early identification of CS in people with knee OA, but further research is needed. [ABSTRACT FROM AUTHOR]