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Purpose: There is a high prevalence of persistent pain following SCI yet insights into its impact and the quality of pain care are limited. We aimed to explore, in-depth, the problem of persistent pain in Australian community-dwelling adults with a spinal cord injury (SCI). Our objectives were to investigate (i) how individuals experience persistent pain, (ii) how they experience pain care and (iii) the concordance between clinical practice guidelines for managing pain and reported care practices., Methods: We conducted a mixed-methods convergent parallel study. Adults with SCI and persistent pain completed a survey ( n  = 43); a subset of participants completed interviews ( n  = 10). We analysed the data from each method separately and then integrated the findings., Results: Results indicated that the life impact of persistent pain is variable but it can be more disabling than physical impairments and compound a sense of isolation and despair. Community-based management was reported to predominantly have a pharmacological focus, with occurrences of opioid misuse apparent in the data. Access to expert, comprehensive and individualised care was frequently reported as inadequate., Conclusion: While some people with SCI and persistent pain can effectively self-manage their pain, for others the impact on quality of life is profound and complex care needs are commonly unmet.IMPLICATIONS FOR REHABILITATIONPersistent pain is a common consequence of SCI and profoundly impacts quality of life.Complex pain care needs are commonly unmet.Individuals require regular, comprehensive, biopsychosocial assessment.The effectiveness of pain management strategies must be monitored on an ongoing basis.Opportunities for personal self-management support must be available long-term.

Complex regional pain syndrome (CRPS) is a distressing and disabling pain condition. Many people with CRPS and the health professionals who treat them seek information about the condition via the Internet. The credibility, accuracy and comprehensiveness of online CRPS information remains unknown. The aim of this study was to determine the credibility, accuracy and comprehensiveness of information presented on freely accessible websites that aim to educate people about CRPS. Keyword searches were conducted on the Australian Google site, with 'trustworthy' websites included and critically appraised. Primary outcomes were recognised metrics of credibility (JAMA benchmark credibility criteria) and website accuracy (according to European CRPS guidelines). Comprehensiveness was assessed using the proportion of European CRPS guidelines covered by the websites. In all, 30 websites with 819 recommendations were critically appraised. Five (17%) websites met all credibility criteria; of the recommendations, 349 (43%) were accurate, 252 (31%) were inaccurate and 218 (26%) were unclear. For comprehensiveness, an average of 17% of general guidelines, 15% of therapeutic guidelines and 6% of medication/supplement guidelines were covered. Online information about CRPS available to Australians has low credibility, accuracy and comprehensiveness. Many website recommendations are inaccurate or unclear, and many websites endorse inappropriate treatments. There is an urgent need for accurate and comprehensive sources of CRPS information online.

Background: Despite well-established benefits of physical activity for knee osteoarthritis (OA), nine of ten people with knee OA are inactive. People with knee OA who are inactive often believe that physical activity is dangerous, fearing that it will further damage their joint(s). Such unhelpful beliefs can negatively influence physical activity levels. We aim to evaluate the clinical- and cost-effectiveness of integrating physiotherapist-delivered pain science education (PSE), an evidence-based conceptual change intervention targeting unhelpful pain beliefs by increasing pain knowledge, with an individualised walking, strengthening, and general education program., Methods: Two-arm, parallel-design, multicentre randomised controlled trial involving 198 people aged ≥50 years with painful knee OA who do not meet physical activity guideline recommendations or walk regularly for exercise. Both groups receive an individualised physiotherapist-led walking, strengthening, and OA/activity education program via 4x weekly in-person treatment sessions, followed by 4 weeks of at-home activities (weekly check-in via telehealth), with follow-up sessions at 3 months (telehealth) and 5 and 9 months (in-person). The EPIPHA-KNEE group also receives contemporary PSE about OA/pain and activity, embedded into all aspects of the intervention. Outcomes are assessed at baseline, 12 weeks, 6 and 12 months. Primary outcomes are physical activity level (step count; wrist-based accelerometry) and self-reported knee symptoms (WOMAC Total score) at 12 months. Secondary outcomes are quality of life, pain intensity, global rating of change, self-efficacy, pain catastrophising, depression, anxiety, stress, fear of movement, knee awareness, OA/activity conceptualisation, and self-regulated learning ability. Additional measures include adherence, adverse events, blinding success, COVID-19 impact on activity, intention to exercise, treatment expectancy/perceived credibility, implicit movement/environmental bias, implicit motor imagery, two-point discrimination, and pain sensitivity to activity. Cost-utility analysis of the EPIPHA-KNEE intervention will be undertaken, in addition to evaluation of cost-effectiveness in the context of primary trial outcomes., Discussion: We will determine whether the integration of PSE into an individualised OA education, walking, and strengthening program is more effective than receiving the individualised program alone. Findings will inform the development and implementation of future delivery of PSE as part of best practice for people with knee OA., Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12620001041943 (13/10/2020)., (© 2021. The Author(s).)

Background: Worldwide, the incidence of wrist fracture is increasing. There are currently no externally validated prognostic models to inform early decision making for these patients., Objectives: 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., Methods: 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., Results: 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)., Conclusion: 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., Level of Evidence: Prognosis, level 1b. J Orthop Sports Phys Ther 2019;49(1):28-35. Epub 12 Sep 2018. doi:10.2519/jospt.2019.8342.

This study explored whether group size and group member characteristics (age, sex, and compensation status) were associated with patient outcomes (changes in pain and disability). Retrospective analyses of outcome data obtained from 2 independently run group cognitive behavioural therapy (CBT) programs for chronic pain (Program A: N = 317 and Program B: N = 693) were conducted. Intracluster correlations were significant in both studies, indicating group-level effects on patient outcomes in both group CBT programs for chronic pain. Mixed modelling revealed that group size and group member characteristics (age, sex, and compensation status) were related to patient outcomes, but not consistently across programs. The results of our analyses confirm the contribution of group composition to individual treatment outcomes in group CBT for chronic pain, and highlight factors that have the potential to contribute to group-level variability in patient outcomes. Further research is needed to identify the mechanisms that account for the impact of group characteristics on the efficacy of CBT for chronic pain.

Background: Marketing communication and brand identity is a fundamental principle of advertising and end-user engagement. Health researchers have begun to apply this principle to trial recruitment in primary care. The aim of this study was to evaluate whether a Teaser Campaign using a series of postcards in advance of a conventional mail-out increases the number of primary care clinics that engage with a clinical trial., Methods: Embedded randomised recruitment trial across primary care clinics (general practitioners and physiotherapists) in the Sydney metropolitan area. Clinics in the Teaser Campaign group received a series of branded promotional postcards in advance of a standard letter inviting them to participate in a clinical trial. Clinics in the Standard Mail group did not receive the postcards., Results: From a total of 744 clinics that were sent an invitation letter, 46 clinics in the Teaser Campaign group and 40 clinics in the Standard Mail group responded (11.6% total response rate). There was no between-group difference in the odds of responding to the invitation letter (odds ratio = 1.18, 95% confidence interval = 0.75-1.85, p = 0.49). For physiotherapy clinics and general practice clinics, the odds ratios were 1.43 (confidence interval = 0.82-2.48, p = 0.21) and 0.77 (confidence interval = 0.34-1.75, p  = 0.54), respectively., Conclusion: A Teaser Campaign using a series of branded promotional postcards did not improve clinic engagement for a randomised controlled trial in primary care.

Introduction: Low back pain is the leading worldwide cause of disability, and results in significant personal hardship. Most available treatments, when tested in high-quality randomised, controlled trials, achieve only modest improvements in pain, at best. Recently, treatments that target central nervous system function have been developed and tested in small studies. Combining treatments that target central nervous system function with traditional treatments directed towards functioning of the back is a promising approach that has yet to be tested in adequately powered, prospectively registered, clinical trials. The RESOLVE trial will be the first high-quality assessment of two treatment programs that combine central nervous system-directed and traditional interventions in order to improve chronic low back pain., Aim: To compare the effectiveness of two treatment programs that combine central nervous system-directed and traditional interventions at reducing pain intensity at 18 weeks post randomisation in a randomised clinical trial of people with chronic low back pain., Design: Two-group, randomised, clinical trial with blinding of participants and assessors., Participants and Setting: Two hundred and seventy-five participants with chronic low back pain that has persisted longer than 3 months and no specific spinal pathology will be recruited from the community and primary care in Sydney, Australia., Interventions: Both of the interventions contain treatments that target central nervous system function combined with treatments directed towards functioning of the back. Adherence to the intervention will be monitored using an individual treatment diary and adverse events recorded through passive capture. Participants are informed prior to providing informed consent that some of the treatments are not active. Blinding is maintained by not disclosing any further information. Complete disclosure of the contents of the intervention has been made with the UNSW HREC (HC15357) and an embargoed project registration has been made on the Open Science Framework to meet the Declaration of Helsinki requirement for transparent reporting of trial methods a priori., Intervention a: Participants randomised to Intervention A will receive a 12-session treatment program delivered as 60-minute sessions, scheduled approximately weekly, over a period of 12 to 18 weeks. All treatment sessions are one-on-one. The program includes a home treatment component of 30minutes, five times per week. The intervention comprises discussion of the participant's low back pain experience, graded sensory training, graded motor imagery training and graded, precision-focused and feedback-enriched, functional movement training. Treatment progression is determined by participant proficiency, with mandatory advancement at set time points with respect to a standard protocol., Intervention B: Participants randomised to Intervention B will receive a 12-session treatment program of the same duration and structure as Intervention A. The intervention comprises discussion of the participant's low back pain experience, transcranial direct current stimulation to the motor and pre-frontal cortices, cranial electrical stimulation, and low-intensity laser therapy and pulsed electromagnetic energy to the area of greatest pain. Treatment is delivered according to published recommendations and progressed with respect to a standard protocol., Measurements: The primary outcome is pain intensity at 18 weeks post randomisation. Secondary outcomes will include disability, depression, pain catastrophising, kinesiophobia, beliefs about back pain, pain self-efficacy, quality of life, healthcare resource use, and treatment credibility. Assessment will occur at baseline and at 18, 26 and 52 weeks after randomisation. Treatment credibility will be assessed at baseline and 2 weeks after randomisation only., Analysis: A statistician blinded to group status will analyse the data by intention-to-treat using linear mixed models with random intercepts. Linear contrasts will be constructed to compare the adjusted mean change (continuous variables) in outcome from baseline to each time point between intervention A and intervention B. This will provide effect estimates and 95% confidence intervals for any difference between the interventions., Significance: Preliminary data suggest that combining treatments that target central nervous system function with traditional interventions is a promising approach to chronic low back pain treatment. In the context of modest effects on pain intensity from most available treatments, this approach may lead to improved clinical outcomes for people with chronic low back pain. The trial will determine which, if either, of two treatment programs that combine central nervous system-directed and traditional interventions is more effective at reducing pain intensity in a chronic low back pain cohort. Central nervous system-directed interventions constitute a completely new treatment paradigm for chronic low back pain management. The results have the potential to be far reaching and change current physiotherapy management of chronic low back pain in Australia and internationally., (Copyright © 2016 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Purpose: Tactile deficits have been understudied in children with unilateral cerebral palsy (UCP) using a limited range of tactile assessments. This study aims to characterize performance across a comprehensive battery of tactile registration and perception assessments in children with UCP and typically developing children (TDC)., Methods: Fifty-two children with UCP (Gross Motor Function Classification System I = 34, II = 18; Manual Ability Classification System I = 36, II = 16) and 34 TDC were assessed using Semmes Weinstein Monofilaments (tactile registration), and single-point localization, double simultaneous, static and moving two-point discrimination, stereognosis, and texture perception (tactile perception)., Results: Children with UCP performed consistently worse with their impaired hand than their unimpaired hand (Z = 2.77-5.61; p < 0.005). Both hands of children with UCP performed worse than either hand of TDC (Z = -2.08 to 5.23; p = 0.037-< 0.001). Forty percent of children with UCP had tactile registration and perception deficits, 37% had perception deficits only and 23% had no tactile deficit. The larger the tactile registration deficit, the poorer the performance on all tactile perceptual tests (r = 0.568-0.670; p < 0.001)., Conclusions: Most children with UCP demonstrate poor tactile perception and over one-third also demonstrate poor tactile registration. We contend that tactile dysfunction may contribute to functional impairment and is a possible target for intervention. [, Implications for Rehabilitation: • Cerebral palsy (CP) is the most prevalent physical disability in childhood, with an incidence of approximately 2 cases per 1000 live births; about 35% of children with CP have unilateral cerebral palsy (UCP).• Assessment and treatment has been focused on the motor impairment; however, it is known that children with UCP are also likely to have sensory impairment.• Understanding the nature and severity of sensory, specifically tactile, impairment in children with UCP will assist therapists to direct treatment accordingly and possibly impact the motor impairment.]