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Introduction: This study compared adverse outcomes and resource use for patients with a diagnosis of pain treated with tapentadol prolonged-release (PR) versus those treated with morphine controlled-release (CR) and oxycodone CR., Methods: Data were sourced from the Clinical Practice Research Datalink (CPRD), a database derived from UK primary care. Patients prescribed tapentadol PR between May 2011 and December 2016 were selected and matched to two groups of controls treated with either morphine CR or oxycodone CR on gender, age, pain duration, pain site, pain aetiology, Charlson index and prior analgesia. Times to first adverse event (constipation or nausea/vomiting) were compared within a Cox proportional hazards model. Rates of primary care contacts, accident and emergency contacts and, for a subset of patients linked to Hospital Episode Statistics (HES), inpatient admissions and outpatient contacts were compared using incidence rate ratios (IRRs) derived from Poisson regression., Results: A total of 1907 patients prescribed tapentadol PR were identified and 1791 (93.9%) had a pain diagnosis. Of these 1246 (65.3%) were matched to morphine controls and 829 (43.4%) to oxycodone controls. Compared to controls, gastrointestinal adverse events with tapentadol PR treatment were reduced; aHR = 0.532 (0.402-0.703; p < 0.001) versus morphine CR and 0.517 (0.363-0.735; p < 0.001) versus oxycodone CR. Compared with morphine CR, primary care contacts [IRR = 0.831 (0.802-0.861)], accident and emergency attendance [0.739 (0.572-0.951)], outpatient contacts [0.917 (0.851-0.989)] and inpatients contacts [0.789 (0.664-0.938)] were reduced. For oxycodone, the respective figures were 0.735 (0.703-0.768), 0.971 (0.699-1.352), 0.877 (0.799-0.962) and 0.748 (0.601-0.932)., Conclusion: Tapentadol PR was associated with significantly fewer adverse gastrointestinal events than morphine CR and oxycodone CR in patients with a diagnosis of pain. There was also significantly reduced primary and secondary care resource use. As with all observational studies, potential bias due to residual confounding and confounding by indication should be considered., Funding: Grünenthal Ltd.

Objective: The aim of the present study was to determine the feasibility of a relaxation-based yoga intervention for rheumatoid arthritis, designed and reported in accordance with Delphi recommendations for yoga interventions for musculoskeletal conditions., Methods: Participants were recruited from a hospital database, and randomized to either eight weekly 75-min yoga classes or a usual care control. Feasibility was determined by recruitment rates, retention, protocol adherence, participant satisfaction and adverse events. Secondary physical and psychosocial outcomes were assessed using self-reported questionnaires at baseline (week 0), week 9 (primary time point) and week 12 (follow-up)., Results: Over a 3-month period, 26 participants with mild pain, mild to moderate functional disability and moderate disease activity were recruited into the study (25% recruitment rate). Retention rates were 100% for yoga participants and 92% for usual care participants at both weeks 9 and 12. Protocol adherence and participant satisfaction were high. Yoga participants attended a median of seven classes; additionally, seven of the yoga participants (54%) reported continuing yoga at home during the follow-up period. No serious adverse events were related to the study. Secondary outcomes showed no group effects of yoga compared with usual care., Conclusions: A relaxation-based yoga programme was found to be feasible and safe for participants with rheumatoid arthritis-related pain and functional disability. Adverse events were minor, and not unexpected from an intervention including physical components. This pilot provides a framework for larger intervention studies, and supports further exploration of yoga as a complex intervention to assist with the management of rheumatoid arthritis., (Copyright © 2017 John Wiley & Sons, Ltd.)

Objective: To evaluate the feasibility of a randomized controlled trial investigating the optimal number of treatment sessions of acupuncture, used as an adjunct to usual care, for managing chronic low back pain., Methods: In total, 45 participants with chronic low back pain were recruited and randomly allocated to receive usual care plus 4, 7, or 10 sessions of acupuncture (15/group). Primary outcomes were recruitment rate, randomization rate, treatment compliance, completion of the outcome measures, and retention rates. Secondary outcomes included back function, pain intensity and bothersomeness, generic health status, activity disability, and participant satisfaction. Data were collected at baseline and discharge, and at 6 and 12 weeks post randomization., Results: The recruitment method was demonstrated to be successful: recruitment rate was 43.7%, and randomization rate was 100%. Compliance with treatment was high among participants (86.7%, 86.7%, and 100% for the 4-, 7-, and 10-session group, respectively). Outcome questionnaires used in this study were found to be appropriate for a future randomized controlled trial. Participant retention rates were 88.9% at discharge and at 6 weeks post randomization and 84.4% at 12 weeks post randomization. Secondary outcomes (except for pain intensity) favored the 10-session acupuncture group at 12 weeks post randomization. Over 90% of participants indicated that they were "very satisfied" and/or "extremely satisfied" with the acupuncture treatment., Conclusion: This study demonstrated that a full-scale randomized controlled trial using the methodology described above is feasible, and such a trial is essential to test the dose dependence of acupuncture.

Dysmenorrhea in the absence of pelvic abnormality is termed primary dysmenorrhea (PD). The health burden and social and economic costs of PD are high as it is reported to be the leading cause of recurrent absenteeism from school or work in adolescent girls and young adults. The belief that exercise works for relieving symptoms in women with PD is based on anecdotal evidence and non-experimental studies. There is very limited evidence from randomized controlled trials (RCTs) to support the use of exercise to reduce the intensity of menstrual pain. The objective of this study is to evaluate the effectiveness of exercise to reduce intensity of pain and improve quality of life in women with PD. We describe the study design of a single-blind (assessor), prospective, two-arm RCT, and the participant characteristics of the 70 women recruited in the age-group 18 to 43 years. The primary outcome of the study is pain intensity. The secondary outcomes of the study are quality of life, functional limitation, sleep, global improvement with treatment, and protocol adherence. The outcomes assessments are done at first menstrual period (baseline, Week 0), 2nd menstrual period (Week 4) and at two additional time points (Week 16 and Week 28) during the trial. The results of the study will provide physiotherapists, medical practitioners, and researchers as well as the women who have PD with new insights, knowledge, and evidence about the use of exercise to manage pain in women with PD., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Low back pain (LBP) is a significant health problem and common reason to visit the GP. Evidence suggests GPs experience difficulty applying evidence-based guidelines., Objective: Explore GPs' underlying beliefs about acute LBP and how these influence their clinical management of patients., Methods: Eleven GPs from one geographical region within New Zealand were recruited by purposive sampling. Audio recordings of semi-structured qualitative interviews were transcribed verbatim. Data were analysed with an Interpretive Description framework., Results: Four key themes emerged related to the causes of acute LBP, GP confidence, communicating diagnostic uncertainty and encouraging movement and activity. Acute LBP was seen as a direct representation of tissue injury, consequently the assessment and management of patients' attitudes and beliefs was not a priority. Participants' confidence was decreased due to a perceived inability to diagnose or influence the tissue injury. Despite this, diagnoses were provided to patients to provide reassurance and meet expectations. Guideline recommendations regarding activity conflicted with a perceived need to protect damaged tissue, resulting in reported provision of mixed messages about the need to be both active and careful., Conclusions: GPs' initial focus upon tissue injury during acute care, and providing a diagnostic label, may influence patients' subsequent alignment with a biomedical perspective and contribute to consultation conflict and patients' perception of blame when discussion of psychosocial influences is introduced. Demonstrating the relevance of the biopsychosocial model to acute LBP may improve GPs' alignment with guidelines, improve their confidence to manage these patients and ultimately improve outcomes., (© The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Many strategies are in use with the intention of preventing or minimising delayed onset muscle soreness and fatigue after exercise. Cold-water immersion, in water temperatures of less than 15°C, is currently one of the most popular interventional strategies used after exercise., Objectives: To determine the effects of cold-water immersion in the management of muscle soreness after exercise., Search Methods: In February 2010, we searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library (2010, Issue 1), MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health (CINAHL), British Nursing Index and archive (BNI), and the Physiotherapy Evidence Database (PEDro). We also searched the reference lists of articles, handsearched journals and conference proceedings and contacted experts.In November 2011, we updated the searches of CENTRAL (2011, Issue 4), MEDLINE (up to November Week 3 2011), EMBASE (to 2011 Week 46) and CINAHL (to 28 November 2011) to check for more recent publications., Selection Criteria: Randomised and quasi-randomised trials comparing the effect of using cold-water immersion after exercise with: passive intervention (rest/no intervention), contrast immersion, warm-water immersion, active recovery, compression, or a different duration/dosage of cold-water immersion. Primary outcomes were pain (muscle soreness) or tenderness (pain on palpation), and subjective recovery (return to previous activities without signs or symptoms)., Data Collection and Analysis: Three authors independently evaluated study quality and extracted data. Some of the data were obtained following author correspondence or extracted from graphs in the trial reports. Where possible, data were pooled using the fixed-effect model., Main Results: Seventeen small trials were included, involving a total of 366 participants. Study quality was low. The temperature, duration and frequency of cold-water immersion varied between the different trials as did the exercises and settings. The majority of studies failed to report active surveillance of pre-defined adverse events.Fourteen studies compared cold-water immersion with passive intervention. Pooled results for muscle soreness showed statistically significant effects in favour of cold-water immersion after exercise at 24 hour (standardised mean difference (SMD) -0.55, 95% CI -0.84 to -0.27; 10 trials), 48 hour (SMD -0.66, 95% CI -0.97 to -0.35; 8 trials), 72 hour (SMD -0.93; 95% CI -1.36 to -0.51; 4 trials) and 96 hour (SMD -0.58; 95% CI -1.00 to -0.16; 5 trials) follow-ups. These results were heterogeneous. Exploratory subgroup analyses showed that studies using cross-over designs or running based exercises showed significantly larger effects in favour of cold-water immersion. Pooled results from two studies found cold-water immersion groups had significantly lower ratings of fatigue (MD -1.70; 95% CI -2.49 to -0.90; 10 units scale, best to worst), and potentially improved ratings of physical recovery (MD 0.97; 95% CI -0.10 to 2.05; 10 units scale, worst to best) immediately after the end of cold-water immersion.Five studies compared cold-water with contrast immersion. Pooled data for pain showed no evidence of differences between the two groups at four follow-up times (immediately, 24, 48 and 72 hours after treatment). Similar findings for pooled analyses at 24, 48 and 72 hour follow-ups applied to the four studies comparing cold-water with warm-water immersion. Single trials only compared cold-water immersion with respectively active recovery, compression and a second dose of cold-water immersion at 24 hours., Authors' Conclusions: There was some evidence that cold-water immersion reduces delayed onset muscle soreness after exercise compared with passive interventions involving rest or no intervention. There was insufficient evidence to conclude on other outcomes or for other comparisons. The majority of trials did not undertake active surveillance of pre-defined adverse events. High quality, well reported research in this area is required.

Background: It has been suggested that health care professional (HCP) attitudes and beliefs may negatively influence the beliefs of patients with low back pain (LBP), but this has not been systematically reviewed. This review aimed to investigate the association between HCP attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of this patient population., Methods: Electronic databases were systematically searched for all types of studies. Studies were selected by predefined inclusion criteria. Methodological quality was appraised and strength of evidence was determined., Results: Seventeen studies from eight countries which investigated the attitudes and beliefs of general practitioners, physiotherapists, chiropractors, rheumatologists, orthopaedic surgeons and other paramedical therapists were included. There is strong evidence that HCP beliefs about back pain are associated with the beliefs of their patients. There is moderate evidence that HCPs with a biomedical orientation or elevated fear avoidance beliefs are more likely to advise patients to limit work and physical activities, and are less likely to adhere to treatment guidelines. There is moderate evidence that HCP attitudes and beliefs are associated with patient education and bed rest recommendations. There is moderate evidence that HCP fear avoidance beliefs are associated with reported sick leave prescription and that a biomedical orientation is not associated with the number of sickness certificates issued for LBP., Conclusion: HCPs need to be aware of the association between their attitudes and beliefs and the attitudes and beliefs and clinical management of their patients with LBP., (© 2011 European Federation of International Association for the Study of Pain Chapters.)

Purpose: This study explored experiences of receiving treatment for musculoskeletal pain (MSKP), particularly choices of complementary and alternative medicine (CAM) and/or conventional treatment, using the illness perception dimension of Leventhal's Self-Regulatory Model as the underpinning model within the broader biopsychosocial framework of the International Classification of Functioning, Disability and Health., Method: A mixed-method study was conducted involving 17 people with MSKP. Data were collected in semi-structured interviews, using a phased approach that included the Brief Illness Perception Questionnaire and open-ended questions about experiences of managing and seeking treatment for MSKP. Questionnaire data were analysed descriptively; interview data were transcribed verbatim and analysed using the principles of Interpretative Phenomenological Analysis., Results: Analysis points to health professionals and participants as gatekeepers to treatment, with gatekeeping based on matters of power, searching for solutions, and managing day to day. The themes Role of the Gatekeeper, Swing of the Interminable Pendulum, and Solution of Soldiering On are discussed in relation to literature about health beliefs and choices of CAM or conventional treatments., Conclusions: Future research could include mixed-method designs to further explore issues of knowledge, beliefs, and control that feed into the role of gatekeepers to treatment, as well as comparing CAM choices between public and privately-funded healthcare.

Unlabelled: This study evaluated the effects of varying frequency, intensity and stimulation site, of transcutaneous electrical nerve stimulation (TENS) in an experimental model of pain. In a double-blind design 240 volunteers were randomised to one of six experimental TENS groups, a sham TENS or control (n=30 per group; gender balanced). Two TENS frequencies (110 or 4 Hz) and two intensities (strong but comfortable or highest tolerable) at a fixed pulse duration (200 micros) were applied at three sites relative to the measurement site (segmentally, extrasegmentally or a combination of these), for 30 min. Pressure pain thresholds (PPT) were measured using a pressure algometer, in the first dorsal interosseous muscle, every 10 min, during stimulation and for a further 30 min. The high frequency, high intensity segmental, and combined stimulation groups, showed rapid onset and significant hypoalgesic effects. This effect was sustained for 20 min post-stimulation in the high frequency segmental group. All other TENS intervention groups showed hypoalgesic responses similar to the sham TENS group, and none of these groups reached a clinically significant hypoalgesic level., Conclusions: The role of TENS frequency, intensity and site are pivotal to achieving optimal hypoalgesic effects, during and after stimulation. Clinical applications of these parameter combinations require further investigations.

This study was designed to assess the analgesic effects of interferential therapy (IFT) on experimentally induced muscular pain under randomized, double-blind, placebo-controlled conditions. After ethical approval and written consent were obtained, 40 healthy human volunteers (20 males: 20 females) aged 18-25 years were recruited and randomly assigned to one of four experimental groups (n = 10 per group: male = female): IFT 1, IFT 2, control or placebo. Delayed onset muscle soreness (DOMS) was induced in the elbow flexors of the non-dominant arm of each subject using a single bout of eccentric exercises to exhaustion. Measurements of isometric peak torque, resting angle, mechanical pain threshold and visual analogue scales were performed at set time points. Treatment was applied for 30 min daily over the biceps brachii muscle, for five consecutive days, according to group allocation. IFT 1 received 10-20 Hz, whilst subjects in IFT 2 were treated with 80-100 Hz (bi-pole; carrier frequency: 4 kHz; pulse duration: 125 microseconds). For the placebo group, the procedure was identical to that in the active treatment groups; however, no interferential current was delivered. The control group received no treatment. No significant between group difference was identified at any time point (P > or = 0.14). However, some inconsistent, yet significant differences in daily treatment effects, interactive effects and effects over time were detected. Based on the results of this study it can be concluded that application of IFT at the parameters used here, had no overall beneficial effect on DOMS.

Objectives: This two-phase study was designed to establish the current use of acupuncture within physiotherapy and to determine the opinions of those who received acupuncture therapy., Design: Retrospective study and questionnaire survey., Patients: Patients who attended an outpatient physiotherapy department over a 2-year period (phase 1, retrospective study of clinical records; n = 599). Patients who had received acupuncture treatment from outpatient physiotherapy (phase 2, patient survey; n = 200)., Main Outcome Measure: Patient records and questionnaire., Results: The patients who attended for outpatient physiotherapy were categorized into three main groups: low back pain, cervical/thoracic spine problems and soft-tissue injuries of peripheral joints. Acupuncture appeared to be used as a secondary form of treatment for these conditions, where other modalities failed rather than being used for best effect. The response rate to the questionnaire was 78%, of whom 60% stated that they had experienced pain relief following their acupuncture therapy, and 31% were still experiencing pain relief. The majority had achieved sufficient relief to carry out daily activities at home (80%) and at work (57%). Ninety-four per cent of respondents were either 'satisfied' or 'very satisfied' with their treatment., Conclusion: Further investigation is required to adequately assess the efficacy of acupuncture as a pain-relieving modality.

The effect of acupuncture upon experimentally induced delayed onset muscle soreness (DOMS) was assessed in a placebo-controlled study under blinded conditions. Volunteers (n = 48; 24 M & 24 F) were randomly allocated to one of four groups: control (20 min rest), placebo (minimal needling at non-acupuncture points), treatment group 1 (acupuncture at classic acupuncture points) and treatment group 2 (acupuncture at 'tender' points). DOMS was induced in the elbow flexors of the non-dominant arm using a standardized eccentric exercise regime. Measurements of elbow range of movement (flexion, extension, relaxed angle), and pain as well as visual analogue scores (VAS), tenderness (using a pressure algometer) were employed as indices of treatment efficacy. Measurements of elbow range of movement and tenderness were made prior to DOMS induction on the first day, and repeated pre- and post-treatment on subsequent days; pain was assessed using visual analogue scales post-induction and post-treatment on the first day, and pre- and post-treatment thereafter. For all conditions, subjects rested supine for a period of 20 min, during which treatment was delivered according to group allocation. Repeated measures and one-way analysis of variance (ANOVA) demonstrated no significant interactive (AB) effects, except for visual analogue scores (P = 0.0483); one factor ANOVA on the second day of the experiment (pre-treatment) indicated significant differences between the control and all other groups. However, such differences were not found on any other day of the experiment. It is concluded that acupuncture has little effect upon the cardinal signs and symptoms of DOMS, at least under the conditions of the current experiment.

Background and Objectives: This study, which was approved by the University's Ethical committee, was conducted to investigate the effectiveness of Combined Low Intensity Laser Therapy/Phototherapy (CLILT) in alleviating the signs and symptoms of Delayed Onset Muscle Soreness (DOMS) over an 11-day period., Study Design/materials and Methods: Thirty-six subjects (18 M: 18 F) were randomly allocated, under strictly controlled double-blind conditions, to one of three experimental conditions: Control, Placebo, and CLILT (660-950 nm; 11 J/cm2; pulsed at 73 Hz). DOMS was induced in a standardised fashion in the non-dominant elbow flexors using repeated eccentric contractions until exhaustion was reached. Subjects returned on five consecutive days, and two days during the following week, for treatment according to group, and assessment of outcome variables including range of motion, pain, and tenderness., Results: While analysis of results using repeated measures and one factor ANOVA with post-hoc tests showed significant changes in all variables over time (P < 0.05) as a result of the induction procedure, there were no significant differences observed between groups., Conclusions: CLILT failed to show any beneficial treatment effect on DOMS, at least at the parameters used here. These results therefore provide no evidence for the claimed biostimulating effects of such therapy.

Two separate studies investigated the hypoalgesic effect of manipulation of Transcutaneous Electrical Nerve Stimulation (TENS) parameters on two models of experimental pain: the Submaximal Effort Tourniquet Technique and cold-pressor pain. For the first study, 32 healthy subjects (16 male and 16 female) attended once for the purpose of cold-pressor pain induction that involved immersion of the nondominant hand in a water bath at 0 degree C. Subjects were allocated to Control, Placebo, or 1 of 2 treatment groups (110 or 4-Hz TENS). Pain threshold measurements (time to withdrawal of hand in seconds) were obtained over six standardised cold pain cycles (i.e., two before stimulation onset, three during stimulation, and one cycle after stimulation). In the second study, 48 healthy volunteers (24 male and 24 female) attended on two occasions, 48 h apart, for the purposes of ischaemic pain induction. On the first attendance, baseline data were obtained and on the second, subjects were randomly allocated to Control, Placebo, or one of four treatment groups with different combinations of stimulation frequencies and pulse durations (4 or 110 Hz and 50 or 200 microseconds). Measurements of "current pain intensity" and "worst pain experienced" were obtained via the Visual Analogue Scale (VAS) and the McGill Pain Questionnaire (MPQ), respectively. Analysis of variance performed on both sets of collected data revealed no significant differences between any of the groups, thus indicating no apparent relevance of manipulation of TENS parameters using these models of pain. Several hypotheses are suggested to explain these findings.

Although Transcutaneous Electrical Nerve Stimulation (TENS) has become a popular modality in pain management over the past 20 yr, there is still debate over its mechanisms of action and the precise relevance of stimulation parameters to its hypoalgesic effects. Thus, confusion still surrounds the selection of optimal stimulation parameters. Two separate studies (total n = 88) were carried out to investigate the effect of four combinations of TENS pulse durations (50 microseconds & 200 microseconds) and frequencies (4 Hz and 110 Hz) on nerve conduction in the human superficial radial nerve and on Mechanical Pain Threshold (MPT) within the associated sensory distribution of the nerve over the dorsum of the hand. Results showed that application of one combination of TENS parameters (110 Hz, 200 microseconds) directly over the course of the nerve produced a significant increase in both peripheral nerve conduction latency (P < or = 0.05; analysis of variance (ANOVA)) and MPT (P < or = 0.01). In addition, there was a high correlation (r = 0.9) between shifts in MPT and negative peak latency for the groups treated with this combination of TENS parameters. The results of this study thus illustrate that combinations of TENS parameters are important to the peripheral neurophysiological effects of this modality and, further, its associated hypoalgesic effects, at least on the model of pain used here.

Background and Objective: This study assessed the putative analgesic effect of combined monochromatic light/laser irradiation at low intensity (660-950 nm; 31.9 J/cm2; pulsed at 16 or 73 Hz)., Study Design/materials and Methods: The investigation was completed under double-blind conditions using a standardised form of the submaximal effort tourniquet technique. Healthy male volunteers naive to the experimental conditions (n = 45) attended on two occasions for the purposes of pain induction, the first during which baseline data were obtained and on a second occasion during which they were randomly allocated to one of two treatments or a placebo condition. For the treatment conditions, irradiation was applied to the ipsilateral Erb's point at the parameters stated; for the placebo condition, sham "irradiation" was delivered using a dummy unit. Pain was measured using computerised visual analogue scales and McGill Pain Questionnaires (MPQ) to assess "current pain intensity" and "worst pain experienced," respectively., Results: Analysis of variance and appropriate post hoc tests demonstrated only a weak (but significant) hypoalgesic effect compared to placebo (P < 0.05) in the treatment group irradiated at 16Hz for the sensory component of the MPQ; other comparisons were found to be nonsignificant., Conclusions: These results do not provide convincing evidence for the hypoalgesic potential of combined monochromatic light/laser irradiation, at least at the parameters used here, and thus indicate the necessity of additional work to investigate this modality further in order to assess the potential benefit, if any, of such treatment in the clinical setting.

Healthcare clinical decision makers' (CDMs) attitudes, beliefs, and biases can negatively contribute to both clinical conversations and subsequent inequitable management decisions in persistent musculoskeletal pain (PMP). Understanding the factors that may contribute to CDMs' decisions is particularly important for vulnerable patient populations. The aim of this systematic review was to synthesize the current research investigating the impact of CDM's attitudes, beliefs, and biases on the process of care in PMP management in adults. A systematic search following PRISMA guidelines was run in five databases: CINAHL, PubMed, Scopus, Sociology Database in ProQuest, and Web of Science. Included studies: vulnerable adult populations with chronic pain. Methodological quality was assessed with the Downs and Black tool. Nine studies were included. Studies examined CDMs' perceptions of case vignettes used in medical schools, allied health professional programs, and in healthcare settings. Implicit biases related to pain severity and favoring medical evidence influenced CDMs' perceptions of case legitimacy. Pharmaceutical management decisions were influenced by race/ethnicity, gender, pain severity, medical evidence, and non-verbal patient behavior. Pain severity influenced non-pharmaceutical management decisions. Implicit biases related to race/ethnicity, gender, supporting medical evidence, and pain severity were demonstrated in educational settings and persisted in clinical settings. Health professional curricula should include training with a focus on outcomes that demonstrate increased awareness of the factors that could lead to inequitable management decisions. Addressing biases during the training of CDMs will be necessary to improve congruency of clinical conversations and minimize marginalization of patient care in PMP. [ABSTRACT FROM AUTHOR]

Objective Chronic musculoskeletal pain (CMP) outcomes are affected by numerous variables, including the clinical conversation. When good therapeutic/working alliances are formed, congruent clinical conversations can lead to improved CMP outcomes. Identifying patient/provider attitudes, beliefs, and biases in CMP that can influence the clinical conversation, and thus clinical management decisions, is foundationally important. Design The aims of this systematic review were to 1) summarize the evidence of the attitudes and beliefs of patients and health care providers (HCPs) involved in the clinical conversation about CMP, and 2) examine whether and how these perceptions impacted the process of care. Methods A systematic search of CINAHL, PubMed, Scopus, Sociology Database in ProQuest, and Web of Science used the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Included studies were those investigating vulnerable adult populations with chronic pain. Study bias was examined with the Downs and Black tool. Results Seven retrospective studies were included. When making pharmaceutical management decisions, HCPs demonstrated negative implicit biases toward minorities and women. When making referrals to multidisciplinary care, HCPs demonstrated negative implicit biases toward women with lower educational attainment. Unmet patient expectations resulted in higher dropout rates at multidisciplinary pain management programs. Patients' trust was influenced by the health care setting, and patients often had limited options secondary to health insurance type/status. Conclusion These findings suggest that patients with CMP may experience a marginalized process of care due to HCPs' negative implicit biases, unmet patient expectations, and the health care setting. Results suggest several factors may contribute to inequitable care and the recalcitrant nature of CMP, particularly in vulnerable populations with limited health care choices. [ABSTRACT FROM AUTHOR]

Background: The chronic musculoskeletal pain (CMP) epidemic occurs concurrently during historical mass population movements and significant income inequities. Epidemiological studies indicate CMP may occur disproportionately in marginalized populations. Nationalistic rhetoric has arisen, in part, due to perceived concerns over access to healthcare. Political policies directly and indirectly impact healthcare. Objectives: To explore 1) how potential historical, societal, and political factors may contribute to the clinical conversation of pain; 2) the impact ineffective clinical conversations may have on the CMP experience. Methods: Literature Review. Major Findings: CMP is an invisible disease decoupled from normal tissue healing. The clinical conversation is increasingly recognized to impact treatment outcomes. The clinician and the patient bring differing histories, values, and interpretations to clinic visits. Systemic healthcare racism, implicit biases, incongruent provider/patient assessment of pain, and provider stigmatization contribute to olgioanalgesia. As healthcare professional groups become more politically active, providers bring that political experience into the clinic. Marginalized populations, at risk for greater stress, discrimination, and fear bring their own intensified political perceptions into the clinic. We suggest that poor management and discordant clinical conversation may be adversely influenced by the current political climate. Conclusion: Identifying contributing factors to ineffective clinical conversations is important to improve CMP outcomes and to minimize inequities in CMP management. We hope to identify populations that may be more vulnerable to political biases, understand factors in the clinical conversation that are important to patients, and to build opportunities to educate providers and patients on these forces impacting the clinical conversation. [ABSTRACT FROM AUTHOR]

Background: Chronic musculoskeletal pain in the elderly is highly prevalent, with osteoarthritis, low back pain, neck pain and other musculoskeletal disorders as the leading contributors to pain chronicity and disability. Previous reviews identifying effective components of non-pharmacological interventions for treating chronic pain have either few studies or the included studies examine outcome over a limited time span. This systematic review will investigate the effectiveness and components of interventions associated with management of chronic musculoskeletal pain in older adults (≥65 years). Methods/Design: This systematic review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance. Randomised controlled trials of non-pharmacological interventions aimed at reducing pain in older adults with chronic musculoskeletal pain will be included. Articles will be identified through a comprehensive search of the following databases: Ovid MEDLINE, Embase, CINAHL, AMED, Scopus, Web of Science and PEDro. Two review authors will independently screen articles retrieved from the search for eligibility, and extract relevant data on methodological issues. A narrative synthesis will be completed if there are insufficient data for a meta-analysis. The narrative synthesis will summarise the current state of knowledge, interventions, study designs and robustness of evidence. Discussion: Findings of the study will inform support programs and interventions to assist people aging with pain, carers and other supporters and practitioners. Systematic review registration: PROSPERO 2017:CRD42017074173. [ABSTRACT FROM AUTHOR]

Abstract: The aim of this review was to determine the factors that impact on doctors’ management of patients with acute low back pain. A methodological assessment of databases (Medline, EMBASE, Psychinfo, BIOSIS, CINAHL, and the Cochrane Central Register of Controlled Trials) identified papers which were screened for inclusion criteria by two independent reviewers. Data were extracted from accepted papers, and the internal validity and strength of the evidence were determined using valid and reliable scales. The search generated a total of 28 papers [quantitative (n =27), qualitative (n =1) methodologies]. Themes were identified from the accepted papers: education (n =18), knowledge of clinical guidelines and impact on management (n =7), and doctors’ demographics (n =4). There was consistent evidence that doctors did not adhere to clinical guidelines when performing a spinal assessment. There was inconsistent evidence that education increased adherence with acute LBP guideline recommendations in terms of referral rates to physiotherapy, for investigations, to secondary care and for maintaining patients at work. Strategies to address the factors impacting on doctors’ management of acute LBP are required; these would lead to improvement in patient outcomes and reduce healthcare costs. [Copyright &y& Elsevier]

Background: Evidence supports the use of exercise for chronic low back pain (CLBP); however, adherence is often poor due to ongoing pain. Auricular acupuncture is a form of pain relief involving the stimulation of points on the outer ear corresponding with specific body parts. It may be a useful adjunct to exercise in managing CLBP; however, there is only limited evidence to support its use with this patient group. Methods/Design: This study was designed to test the feasibility of an assessor-blind randomised controlled trial which assess the effects on clinical outcomes and exercise adherence of adding manual auricular acupuncture to a personalised and supervised exercise programme (PEP) for CLBP. No sample size calculation has been carried out as this study aims to identify CLBP referral rates within the catchment area of the study site. The researchers aim to recruit four cohorts of n = 20 participants to facilitate a power analysis for a future randomised controlled trial. A computer generated random allocation sequence will be prepared centrally and used to allocate participants by cohort to one of the following interventions: 1) six weeks of PEP plus manual auricular acupuncture; 2) six weeks of PEP alone. Both groups will also complete a further six weeks of self-paced exercise with telephone follow-up support. In addition to a baseline and exit questionnaire at the beginning and end of the study, the following outcomes will be collected at baseline, and after 7, 13 and 25 weeks: pain frequency and bothersomeness, back-specific function, objective assessment and recall of physical activity, use of analgesia, perceived self-efficacy, fear avoidance beliefs, and beliefs about the consequences of back pain. Since this is a feasibility study, significance tests will not be presented, and treatment effects will be represented by point estimates and confidence intervals. For each outcome variable, analysis of covariance will be performed on the data, conditioning on the baseline value. Discussion: The results of this study investigating the adjuvant effects of auricular acupuncture to exercise in managing CLBP will be used to inform the design of a future multi-centre randomised controlled trial. Trial Registration: Current Controlled Trials ISRCTN94142364. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editor discusses various reports within the issue including musculoskeletal pain, psychological interventions and physiotherapy to improve pain conditions and the use of digital technologies to promote physical activity.

An abstract of the study "Yoga for Pain and Sleep Quality in Rheumatoid Arthritis: A Pilot Randomized Controlled Trial," by Lesley Ward, Simon Stebbings, Josie Athens, Daniel Cherkin and G. David Baxter is presented.

To evaluate the effectiveness of a treadmill-based aerobic exercise intervention on pain and associated symptoms of primary dysmenorrhea. Seventy women with primary dysmenorrhea were included in the study. The experimental group underwent supervised aerobic training for 4 weeks followed by unsupervised home exercise for the next 6 months. The control group continued usual care. The primary outcome was pain. Secondary outcomes included quality of life (QoL), daily functioning, and sleep. After the 4-week training, compared to the control group exercise significantly improved primary outcomes pain quality (mean difference (MD) -1.9, 95% CI 3.8 to −0.04, p <.05), and intensity (MD -4.7, 95% CI -9.3 to −0.09, p <.05), but not present pain. Significant effects were also reported for pain interference (MD -1.7, 95% CI -3.4 to −0.02, p <.05) at 4 weeks; the other outcomes did not significantly differ between groups at this time. During the follow-up period of 7-months, the effect on pain improved to 22 mm (95% CI 18 to 25). Significant benefits of exercise were maintained up to 7-months for present pain, QoL and daily functioning. Exercise has significant effects on primary dysmenorrhea-related pain, QoL and function. ACTRN12613001195741. [ABSTRACT FROM AUTHOR]

Aims: The aim was to investigate peoples’ experiences of the impact of chronic low back pain. Background: Chronic low back pain is a complex disorder with wide-ranging adverse consequences that can impact on people''s lifestyles and self-image. It is also a condition that can sometimes be treated with some scepticism by health care providers and other people in the person''s life. It has been suggested that further research into the subjective experience of chronic blow back pain is needed to develop a better understanding of its impact. Design: This study is a qualitative analysis of semi-structured interviews with 64 participants identified as having chronic low back pain who were interviewed about the impact of the condition on their lives. The data were analysed using a method of inductive thematic analysis. Findings: Four main themes were identified: the unpredictability of the pain, the need for vigilance, the externalization/objectification of the body and the alteration to sense of self. Conclusion: Nurses have an important role to play in working with patients experiencing chronic low back pain to identify any patterns associated with exacerbations of the condition, validating their experiences of chronic low back pain and facilitating the accommodation of chronic low back pain into a more satisfying sense of self. [Copyright &y& Elsevier]