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Worldwide, the incidence of wrist fracture is increasing. There are currently no externally validated prognostic models to inform early decision making for these patients.To develop and validate a prognostic model from a comprehensive range of candidate prognostic factors that can identify patients who are at risk of developing persistent pain following wrist or hand fracture.We developed and validated a prognostic model using secondary data derived from a prospective cohort study (n = 715), with recruitment sites in 3 metropolitan hospitals in Sydney, Australia. The primary outcome was persistent pain 4 months following the injury. The current study used a backward stepwise regression analysis to develop the model in 2 hospitals (n = 408) and externally validate it in a third hospital (n = 307). To determine the accuracy of the model, we assessed calibration and discrimination in accordance with the PROGnosis RESearch Strategy framework.Complete data were available for 95% of the cohort. Of 14 candidate variables, the final model contained 2 prognostic factors: patient age and pain intensity reported at initial presentation. The area under the receiver operating characteristic curve was 0.63 (95% confidence interval: 0.56, 0.69) in the development sample and 0.61 (95% confidence interval: 0.51, 0.70) in the validation sample. The model systematically overestimated risk (intercept, -1.13; slope, 0.73).We developed and externally validated a prognostic model to predict persistent pain 4 months after a wrist or hand fracture. Future studies are needed to assess whether the accuracy of this model can be improved by updating and validating it in local settings.Prognosis, level 1b. J Orthop Sports Phys Ther 2019;49(1):28-35. Epub 12 Sep 2018. doi:10.2519/jospt.2019.8342.

The purpose of this longitudinal blood sampling study was to examine relationships between sex hormones and fibromyalgia pain. Eight women meeting case definition criteria for fibromyalgia provided venous blood samples and reported their fibromyalgia pain severity over 25 consecutive days. All women exhibited normal menstrual cycles and were not taking oral contraceptives. Cortisol, and the sex hormones estradiol, progesterone, and testosterone, were assayed from serum. A linear mixed model was used to determine if fluctuations of sex hormones were associated with changes in pain severity. In the entire sample, day to day changes in progesterone (P = .002) as well as testosterone (P = .015) were significantly and inversely correlated with pain severity. There was no relationship between estradiol and pain (P = .551) or cortisol and pain (P = .633). These results suggest that progesterone and testosterone play a protective role in fibromyalgia pain severity. Sex and other hormones may serve to increase as well as decrease fibromyalgia pain severity. Perspective Sex hormones fluctuate normally in women with fibromyalgia, but may still contribute to pain severity.

That complex regional pain syndrome (CRPS) is associated with functional reorganization in the primary somatosensory cortex (S1) is widely accepted and seldom questioned. Despite more than a decade of research, there has been no systematic review of the CRPS literature concerning the changes in S1 function, and therefore the extent of these changes is unclear. Here we conduct a systematic review and meta-analysis to quantify the spatial and temporal aspects of S1 function in CRPS. A comprehensive search strategy identified functional neuroimaging studies of S1 in CRPS. We adhered to a rigorous systematic review protocol when extracting data and appraising risk of bias. Outcomes were grouped into spatial representation; activation levels, including disinhibition; peak latency of activation; and glucose metabolism. Meta-analysis was conducted where possible. Fifteen studies were included, all investigating upper-extremity CRPS. In patients with CRPS, the S1 spatial representation of the affected hand is smaller than that of the unaffected hand and that of non-CRPS controls; however, this evidence comes from only a few studies. There is no difference in activation, disinhibition, or latency of peripherally evoked S1 responses in CRPS. The risk of bias was high across studies, mainly from unclear sampling methods and unblinded analysis of outcomes. Perspective: The evidence for a difference in function of the primary somatosensory cortex in CRPS compared with controls is clouded by high risk of bias and conflicting results, but reduced representation size seems consistent. Refereed/Peer-reviewed

Objective: Chronic pain is a common problem that is associated with mood disorders such as depression. The Depression, Anxiety, and Stress Scales (DASS-21) questionnaire is commonly used to help measure disordered mood. In this study, we used Rasch analysis to analyze the clinimetric properties of the DASS-21 in a chronic low back pain sample. Study Design and Setting: A Rasch analysis was conducted on data collected as a part of a randomized hospital-based placebo controlled trial. DASS-21 questionnaires were completed by the 154 enrolled participants. Results: The DASS-21 subscales fit the Rasch model. No differential item functioning was detected for age, gender, pain severity, or disability. Reliability for individual use was supported for the depression subscale (Person Separation Index [PSI]50.86) but group use only for the anxiety (PSI50.74) and stress (PSI50.82) subscales. A DASS-21 aggregate score of ‘‘negative affect’’ lacked fit to the Rasch model (c25191.48, P!0.001). Conclusion: This is the first study that used Rasch analysis to demonstrate that the DASS-21 subscales demonstrate adequate measurement properties for research involving groups with chronic pain. Only the DASS-21 depression subscale demonstrated adequate reliability for use with individuals with chronic pain. The use of a single DASS-21 aggregate score as a measure of ‘‘negative affect’’ was not supported. Refereed/Peer-reviewed

Background and Purpose Orofacial pain disorders are relatively uncommon and pose a substantial diagnostic challenge. This case report documents the diagnosis and management of hemifacial pain in a patient who was referred to an interdisciplinary pain medicine unit. The purpose of this case report is twofold. First, it presents complex regional pain syndrome (CRPS) as a potential differential diagnosis in cases of facial pain. Second, it describes the successful adaption of contemporary management approaches for distal-extremity CRPS to treat people with CRPS of the facial region. Case Description The patient had hemifacial pain and concomitant motor and autonomic symptoms after a small laceration of the eyelid. Extensive specialist medical evaluations were undertaken to exclude an underlying structural pathology. After detailed clinical assessments by a physical therapist, pain physician, and clinical psychologist, a diagnosis of CRPS involving the face was made. Outcomes The patient's pain was largely unresponsive to pharmacological agents. A modified graded motor imagery program, together with desensitization and discrimination training, was commenced by the physical therapist and clinical psychologist. A positive clinical response was indicated by a decrease in allodynia, normalization of motor control, and regained function in activities of daily living. Discussion Complex regional pain syndrome is an infrequently reported differential diagnosis that can be considered in patients with persistent facial pain. This case report highlights how careful examination and clinical decision making led to the use of an innovative therapeutic strategy to manage a challenging condition.

Upper limb fracture is a common musculoskeletal injury and can lead to marked pain-related disability. Unlike other common painful musculoskeletal conditions, such as low back pain, little consideration has been given to the role that psychological variables may play in explaining the relationship between pain and disability during early fracture recovery. This cross-sectional study aimed to determine if psychological distress (symptoms of depression, anxiety, and/or stress) mediate the relationship between pain and disability in acute hand/wrist fractures. Self-reported data from a consecutive sample of 594 patients with acute hand/wrist fracture were used. Mediation analyses were conducted to determine the role of depression, anxiety, and stress in the relationship between pain and disability, controlling for relevant demographic and fracture-related variables. Depression and stress, but not anxiety, significantly mediated the relationship between pain and disability. That is, although each psychological distress variable was associated with pain (P.001), only depression (b1 = 0.27, P = .03) and stress (b3 = .23, P = .02) were significantly associated with disability and fulfilled recommended criteria for establishing a mediating variable. Increased depression and stress, but not anxiety, explain the relationship between pain and disability and may be novel targets for interventions designed to reduce pain-related disability after upper limb fracture. Perspective: This study presents the mediating effect of psychological distress on the relationship between pain and disability in acute upper limb fracture. These factors may be novel targets for interventions designed to reduce pain-related disability after acute fracture.

Editors' Note: Parkitny and O'Connell point out the divergence in the initial hypothesis and final article on repetitive transcranial magnetic stimulation for fibromyalgia and critique how the authors interpreted the study results. Guedj and Boyer, authors of the study, respond. Freeman makes interesting observations and raises questions regarding the higher rate of intensive care unit admission and mortality in patients with multiple sclerosis. Marrie and Garland offer additional clarification. —Chafic Karam, MD, and Robert C. Griggs, MD Boyer et al.1 diverge—without disclosure—from the registered protocol for this trial. The authors stated that …

Background The Pain Self-Efficacy Questionnaire (PSEQ) is used by physical therapists in clinical practice and in research. However, current understanding of the PSEQ's measurement properties is incomplete, and investigators cannot be confident that it provides unbiased information on patient self-efficacy. Objective The aims of this study were: (1) to investigate the scale properties of the PSEQ using Rasch analysis and (2) to determine whether age, sex, pain intensity, pain duration, and pain-related disability bias function of the PSEQ. Design This was a retrospective study; data were obtained from 3 existing studies. Methods Data were combined from more than 600 patients with low back pain of varying duration. Rasch analysis was used to evaluate targeting, category ordering, unidimensionality, person fit, internal consistency, and item bias. Results There was evidence of adequate category ordering, unidimensionality, and internal consistency of the PSEQ. Importantly, there was no evidence of item bias. Limitations The PSEQ did not adequately target the sample; instead, it targeted people with lower self-efficacy than this population. Item 7 was hardest for participants to endorse, showing excessive positive misfit to the Rasch model. Response strings of misfitting persons revealed older participants and those reporting high levels of disability. Conclusions The individual items of the PSEQ can be validly summed to provide a score of self-efficacy that is robust to age, sex, pain intensity, pain duration, and disability. Although item 7 is the most problematic, it may provide important clinical information and requires further investigation before its exclusion. Although the PSEQ is commonly used with people with low back pain, of whom the sample in this study was representative, the results suggest it targets patients with lower self-efficacy than that observed in the current sample.

Cytokine concentrations are thought to be affected by methods of sampling and processing and by storage conditions. In this study we compared 17 cytokine concentrations obtained from plasma and serum at baseline and after a controlled thaw condition. We found that absolute agreement was poor between concentrations of cytokines in plasma and serum, except for MIP1β. A thaw condition significantly changed the concentrations of most cytokines, but serum appeared less affected by this than plasma was. Closer examination using Bland-Altman analyses revealed that for each comparison, agreement was moderately good for many cytokine concentrations. This is important because measures of agreement must be interpreted based on the required precision, which may differ between clinical and research demands. We also identified that for some cytokines, the relationship between serum and plasma is affected by concentration, thus advocating for the use of appropriate methods when performing such comparisons in studies such as systematic reviews and meta-analyses.