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Background: Perceived diagnostic uncertainty can leave adolescents confused about their condition and impede their ability to understand "what's wrong with me". Our aim is to develop credible explanations about the condition for adolescents suffering from non‐traumatic knee pain. Methods: This multiple‐method study integrated findings from two systematic literature searches of qualitative and quantitative studies, an Argumentative Delphi with international experts (n = 16) and think‐aloud interviews with adolescents (n = 16). Experts provided feedback with arguments on how to communicate credible explanations to meet adolescents' needs; we analysed feedback using thematic analysis. The explanations were tailored based on the adolescent end‐users' input. Results: We screened 3239 titles/abstracts and included 16 papers exploring diagnostic uncertainty from adolescents' and parents' perspectives. Five themes were generated: (1) understanding causes and contributors to the pain experience, (2) feeling stigmatized for having an invisible condition, (3) having a name for pain, (4) controllability of pain, and (5) worried about something being missed. The Argumentative Delphi identified the following themes: (1) multidimensional perspective, (2) tailored to adolescents, (3) validation and reassurance, and (4) careful wording. Merging findings from the systematic search and the Delphi developed three essential domains to address in credible explanations: "What is non‐traumatic knee pain and what does it mean?", "What is causing my knee pain?" and "How do I manage my knee pain?" Conclusions: Six credible explanations for the six most common diagnoses of non‐traumatic knee pain were developed. We identified three domains to consider when tailoring credible explanations to adolescents experiencing non‐traumatic knee pain. Significance: This study provides credible explanations for the six most common diagnoses of non‐traumatic knee pain. Additionally, we identified three key domains that may need to be addressed to reduce diagnostic uncertainty in adolescents suffering from pain complaints. Based on our findings, we believe that clinicians will benefit from exploring adolescents' own perceptions of why they experience pain and perceived management strategies, as this information might capture important clinical information when managing these young individuals. [ABSTRACT FROM AUTHOR]

Background: Alcohol withdrawal is a common reason for admission to acute care hospitals. Prescription of medications for alcohol-use disorder (AUD) and close outpatient follow-up are commonly recommended, but few studies report their effects on postdischarge outcomes., Objectives: The objective of this study is to evaluate the effects of medications for AUD and follow-up appointments on readmission and abstinence., Methods: This retrospective cohort study evaluated veterans admitted for alcohol withdrawal to medical services at 19 Veteran Health Administration hospitals between October 1, 2018 and September 30, 2019. Factors associated with all-cause 30-day readmission and 6-month abstinence were examined using logistic regression., Results: Of the 594 patients included in this study, 296 (50.7%) were prescribed medications for AUD at discharge and 459 (78.5%) were discharged with follow-up appointments, including 251 (42.8%) with a substance-use clinic appointment, 191 (32.9%) with a substance-use program appointment, and 73 (12.5%) discharged to a residential program. All-cause 30-day readmission occurred for 150 patients (25.5%) and 103 (17.8%) remained abstinent at 6 months. Medications for AUD and outpatient discharge appointments were not associated with readmission or abstinence. Discharge to residential treatment program was associated with reduced 30-day readmission (adjusted odds ratio [AOR]: 0.39, 95% confidence interval [95% CI]: 0.18-0.82) and improved abstinence (AOR: 2.50, 95% CI: 1.33-4.73)., Conclusions: Readmission and return to heavy drinking are common for patients discharged for alcohol withdrawal. Medications for AUD were not associated with improved outcomes. The only intervention at the time of discharge that improved outcomes was discharge to residential treatment program, which was associated with decreased readmission and improved abstinence., (Published 2024. This article is a US Government work and is in the public domain in the USA.)

Introduction: Musculoskeletal pain is a significant public health concern in Europe. With the advent of the digital age, online health information-seeking behaviour has become increasingly important, influencing health outcomes and the ability of individuals to make well-informed decisions regarding their own well-being or of those they are responsible for. This study protocol outlines an investigation into how individuals in five European countries (Austria, Denmark, Ireland, Italy, and Spain) seek online health information for musculoskeletal pain., Methods: The protocol adopts an exploratory and systematic two-phase approach to analyse online health information-seeking behaviour. Phase 1 involves four steps: (1) extraction of an extensive list of keywords using Google Ads Keyword Planner; (2) refinement of the list of keywords by an expert panel; (3) investigation of related topics and queries and their degree of association with keywords using Google Trends; and (4) creation of visual representations (word clouds and simplified network graphs) using R. These visual representations provide insights into how individuals search for online health information for musculoskeletal pain. Phase 2 identifies relevant online sources by conducting platform-specific searches on Google, X, Facebook, and Instagram using the refined list of keywords. These sources are then analysed and categorised with NVivo and R to understand the types of information that individuals encounter., Conclusions: This innovative protocol has significant potential to advance the state-of-the-art in digital health literacy and musculoskeletal pain through a comprehensive understanding of online health information-seeking behaviour. The results may enable the development of effective online health resources and interventions., (© The Author(s) 2024.)

Objectives: Few studies describe contemporary alcohol withdrawal management in hospitalized settings or review current practices considering the guidelines by the American Society of Addiction Medicine (ASAM)., Methods: We conducted a retrospective cohort study of patients hospitalized with alcohol withdrawal on medical or surgical wards in 19 Veteran Health Administration (VHA) hospitals between October 1, 2018, and September 30, 2019. Demographic and comorbidity data were obtained from the Veteran Health Administration Corporate Data Warehouse. Inpatient management and hospital outcomes were obtained by chart review. Factors associated with treatment duration and complicated withdrawal were examined., Results: Of the 594 patients included in this study, 51% were managed with symptom-triggered therapy alone, 26% with fixed dose plus symptom-triggered therapy, 10% with front loading regimens plus symptom-triggered therapy, and 3% with fixed dose alone. The most common medication given was lorazepam (87%) followed by chlordiazepoxide (33%), diazepam (14%), and phenobarbital (6%). Symptom-triggered therapy alone (relative risk [RR], 0.68; 95% confidence interval [CI], 0.57-0.80) and front loading with symptom-triggered therapy (RR, 0.75; 95% CI, 0.62-0.92) were associated with reduced treatment duration. Lorazepam (RR, 1.20; 95% CI, 1.02-1.41) and phenobarbital (RR, 1.28; 95% CI, 1.06-1.54) were associated with increased treatment duration. Lorazepam (adjusted odds ratio, 4.30; 95% CI, 1.05-17.63) and phenobarbital (adjusted odds ratio, 6.51; 95% CI, 2.08-20.40) were also associated with complicated withdrawal., Conclusions: Overall, our results support guidelines by the ASAM to manage patients with long-acting benzodiazepines using symptom-triggered therapy. Health care systems that are using shorter acting benzodiazepines and fixed-dose regimens should consider updating alcohol withdrawal management pathways to follow ASAM recommendations., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

SYNOPSIS: Understanding the descending pain modulatory system allows for a neuroscientific explanation of naturally occurring pain relief. Evidence from basic science and clinical studies on the effectiveness of drugs in certain patient groups led to pharmacological manipulation of the descending pain modulatory system for analgesia. Understanding mechanisms and theories helps clinicians make sense of chronic musculoskeletal pain. This editorial explains how test paradigms, including conditioned pain modulation, offset analgesia, and stress-induced analgesia work, provide an overview of a placebo analgesia circuitry, and discusses how evoking activity in the descending pain modulatory system using specific paradigms can give new insights into how specific treatments work to reduce pain. J Orthop Sports Phys Ther 2024;54(2):1-6. doi:10.2519/jospt.2024.12113 .

Synopsis: To understand the neuroscience of pain relief, one must know about the descending pain modulatory system. Neuronal pathways that originate in the brainstem and project to the spinal cord to modulate spinal neuronal activity provide a well-documented perspective on the mechanisms of analgesia that underpin pharmacological and nonpharmacological treatment options for people with musculoskeletal pain. Peripheral stimuli or signals from the cortex and subcortical regions of the brain can trigger the descending pain modulatory system (DPMS). The system helps explain how counter-stimulation techniques (eg, acupuncture and manual therapy), the patients' expectations and beliefs, and social or contextual factors could influence how people experience pain. J Orthop Sports Phys Ther 2024;54(2):1-4. doi:10.2519/jospt.2024.12112 .

Background: Limited knowledge exists on the self-reported characteristics of patients seeking primary care physiotherapy in Denmark., Objectives: To describe primary symptom site, co-occurrent pain sites, pain intensity, symptom duration, and number of symptom episodes in patients seeking primary care physiotherapy using patient-reported data., Methods: Cross-sectional study of patients seeking primary care physiotherapy within a nationwide network of clinics in Denmark (FysioDanmark ® ). Data from the FysioDanmark ® clinical database with patient-reported information obtained from questionnaires distributed to patients prior to their first consultation were used. This included primary symptom site, co-occurrent pain sites, pain intensity (0-10 numeric rating scale), symptom duration, and number of symptom episodes., Results: Data from 61,097 patients (57% female) aged 42 years (interquartile range 29-53) and 63,566 first visits were included. The most common reasons for seeking care were back- (22.9%), non-specific- (19.8%) and shoulder symptoms (15.9%). The majority of patients (89.4%) reported symptoms lasting longer than 7 days, and many experienced recurrent episodes. Median pain intensity ranged from 3 to 5 across primary symptom sites and age groups. In general, females reported higher pain intensity than males., Conclusion: Danish patients seeking primary care physiotherapy most commonly presented with back, non-specific, and shoulder symptoms, with mild-to-moderate pain lasting longer than 7 days, and many with recurrent episodes., (© 2023 John Wiley & Sons Ltd.)

Musculoskeletal (MSK) pain is 1 of the most common problems managed by clinicians in MSK care. This article reviews current frameworks for the assessment and management of MSK pain within evidence-based physical therapy practice. Key considerations related to the biopsychosocial model of pain, evidence-based practice, assessment, treatment, physical activity/movement behavior, risk stratification, communication as well as patient education and self-management skills within physical therapy and physical and rehabilitation medicine are addressed. The future direction of MSK pain management is also discussed, including strategies to promote evidence-based practice, behavior change, social prescribing, and the use of technologies., (© 2023 The Authors.)

Competing Interests: Competing interests: MH has received support from professional and scientific bodies (reimbursement of travel costs and speaker fees) for lectures on pain, and he receives book royalties from Gyldendal, Munksgaard Denmark, FADL and Muusmann publications. TS has received payment for lectures relating to pain and rehabilitation.

Spinal pain in adults is a significant burden, from an individual and societal perspective. According to epidemiologic data, spinal pain is commonly found in children and adolescents, where evidence emerging over the past decade has demonstrated that spinal pain in adults can, in many cases, be traced back to childhood or adolescence. Nevertheless, very little focus has been on how to best manage spinal pain in younger age groups. The purpose of this article is to put the focus on spinal pain in children and adolescents and highlight how and where these problems emerge and how they are commonly dealt with. We will draw on findings from the relevant literature from adults to highlight potential common pathways that can be used in the management of spinal pain in children and adolescents. The overall focus is on how healthcare professionals can best support children and adolescents and their caregivers in making sense of spinal pain (when present) and support them in the self-management of the condition.

Objective: To study the effects of supervised training in adults with subacromial pain syndrome., Data Sources: Embase, MEDLINE, Cochrane Library, Cumulative Index to Nursing and Allied Health, and Physiotherapy Evidence Database were searched from inception to March 2020., Study Selection: Independent reviewers selected randomized controlled trials comparing supervised training with (1) no training or (2) self-training in adults with subacromial pain syndrome lasting for at least 1 month. Critical outcomes were shoulder pain, function, and patient-perceived effect. Important outcomes included other potential benefits and adverse events at 3-month follow-up., Data Extraction: Two independent reviewers extracted data for the meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias tool 1, and certainty of evidence was evaluated using the Grades of Recommendation Assessment, Development, and Evaluation (GRADE)., Data Synthesis: Ten studies (n=597, 43% female) were included. Supervised training resulted in larger improvements than no training on pain (at rest: n=286; mean difference [MD], 1.68; 95% confidence interval [CI], 0.31-3.06 on 0-10 scale; during movement: n=353; MD, 1.84; 95% CI,0.91-2.76), function (n=396; standardized MD, 0.30; 95% CI, 0.07-0.52), and patient-perceived effect (n=118; risk ratio, 1.43; 95% CI, 0.87-2.34). Supervised training had potential benefits regarding quality of life, return to work, dropout, and training adherence, albeit more patients reported mild, transient pain after training. Supervised training and self-training showed equal improvements on pain (n=44) and function (n=76), with no data describing patient-perceived effect. Certainty of evidence was low for critical outcomes and low-moderate for other outcomes., Conclusions: Supervised training might be superior to no training and equally effective as self-training on critical and important outcomes. Based on low-moderate certainty of evidence, these findings support a weak recommendation for supervised training in adults with subacromial pain syndrome., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Importance: Persistent (>4 weeks) postconcussion symptoms (PPCS) are challenging for both patients and clinicians. There is uncertainty about the effect of commonly applied nonpharmacological treatments for the management of PPCS., Objective: To systematically assess and summarize evidence for outcomes related to 7 nonpharmacological interventions for PPCS in adults (aged >18 years) and provide recommendations for clinical practice., Data Sources: Systematic literature searches were performed via Embase, MEDLINE, PsycINFO, CINAHL, PEDro, OTseeker, and Cochrane Reviews (via MEDLINE and Embase) from earliest possible publication year to March 3, 2020. The literature was searched for prior systematic reviews and primary studies. To be included, studies had to be intervention studies with a control group and focus on PPCS., Study Selection: A multidisciplinary guideline panel selected interventions based on frequency of use and need for decision support among clinicians, including early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of neck and back, oculomotor vision treatment, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. To be included, studies had to be intervention studies within the areas of the predefined clinical questions, include a control group, and focus on symptoms after concussion or mild traumatic brain injury., Data Extraction and Synthesis: Extraction was performed independently by multiple observers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for data abstraction and data quality assessment. Included studies were assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool and the Cochrane Risk of Bias (randomized clinical trials) tool. Meta-analysis was performed for all interventions where possible. Random-effects models were used to calculate pooled estimates of effects. The level and certainty of evidence was rated and recommendations formulated according to the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework., Main Outcomes and Measures: All outcomes were planned before data collection began according to a specified protocol. The primary outcomes were the collective burden of PPCS and another outcome reflecting the focus of a particular intervention (eg, physical functioning after graded exercise intervention)., Results: Eleven systematic reviews were identified but did not contribute any primary studies; 19 randomized clinical trials comprising 2007 participants (1064 women [53.0%]) were separately identified and included. Evidence for the 7 interventions ranged from no evidence meeting the inclusion criteria to very low and low levels of evidence. Recommendations were weak for early information and advice, graded physical exercise, vestibular rehabilitation, manual treatment of the neck and back, psychological treatment, and interdisciplinary coordinated rehabilitative treatment. No relevant evidence was identified for oculomotor vision treatment, so the panel provided a good clinical practice recommendation based on consensus., Conclusions and Relevance: Based on very low to low certainty of evidence or based on consensus, the guideline panel found weak scientific support for commonly applied nonpharmacological interventions to treat PPCS. Results align with recommendations in international guidelines. Intensified research into all types of intervention for PPCS is needed.

Introduction: Work-related musculoskeletal (MSK) pain is a highly prevalent condition and one of the main contributors to disability and loss of work capacity. Current approaches to the management and prevention of work-related MSK pain do not consistently integrate current evidence-based knowledge and seem to be outdated. The Prevent4Work (P4W) Project aims to collect and spread evidence-based information to improve the management and prevention of work-related MSK pain. P4W will longitudinally investigate (1) risk factors associated with the prevalence of work-related MSK pain, (2) predictive factors for new events of work-related MSK pain in the short term and (3) the modification of pain beliefs after participating in evidence-based e-learning courses., Methods and Analysis: This project employs a mixed-methods design with international cohorts of workers from Spain, Italy and Denmark. All participants will be assessed using self-reported variables at baseline (ie, cross-sectional design) with follow-up after 3 and 6 months (ie, prospective-predictive design). Throughout the first phase (0-3 months), all participants will be offered to self-enrol in e-learning courses on work-related MSK pain. Changes in pain beliefs (if any) will be assessed. The dataset will include sociodemographic characteristics, physical and psychological job demands, lifestyle-related factors, MSK pain history and pain beliefs. At baseline, all participants will additionally complete the P4W questionnaire developed to detect populations at high risk of suffering work-related MSK pain.Descriptive statistics, binary logistic regression, and analysis of variance will be used to identify the significant factors that influence the history of work-related MSK pain, evaluate the short-term prediction capacity of the P4W questionnaire, and investigate whether workers' participation in e-learning courses will modify their pain beliefs., Ethics and Dissemination: The study received ethical approval from the Ethical Committee of San Jorge University (USJ011-19/20). The results will be made available via peer-reviewed publications, international conferences and P4W official channels., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Stress and pain have been interrelated in clinical widespread pain conditions. Studies indicate that acute experimental stress in healthy volunteers has a negative effect on the descending inhibitory pain control system and thus the ability to inhibit one painful stimulus with another (conditioned pain modulation [CPM]) although without effect on general pain sensitivity. CPM effects can be assessed immediately after the stress induction, whereas some physiological stress responses (e.g., cortisol release) are delayed and longer lasting. It is unclear whether CPM may relate to stress-induced increases in cortisol., Design: Twenty-five healthy men had CPM effects measured over a period of 10 minutes. Pain detection thresholds (PDTs) were assessed by repeated test stimuli with cuff algometry on one leg, with and without painful cuff pressure conditioning on the contralateral leg. CPM effects, assessed as the increase in PDT during conditioning stimulation compared with without, were measured before and after experimental stress and a control condition (Montreal Imaging Stress Task [MIST]). Saliva cortisol levels and self-perceived stress were collected., Results: Participants reported the MIST to be more stressful compared with the MIST control, but cortisol levels did not change significantly from baseline. In all sessions, PDT increased during conditioning (P = 0.001), although the MIST compared with the MIST control had no significant effect on PDT or CPM effects. A negative correlation between changes in cortisol and conditioned PDT was found when applying the MIST (P < 0.03)., Conclusions: No significant effect of stress was found on CPM compared with a matched control condition. Individual changes in experimental stress and in conditioned pain sensitivity may be linked with cortisol., (© 2019 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Efficacy of pain modulation is assessed as the difference in pain sensitivity during a painful conditioning, compared to before (conditioning pain modulation, CPM). Attention can be assessed with the Stroop task, in which participants report the number of words on a screen; either congruent or incongruent with the value of the words. Attention away from painful stimuli during CPM enhances the CPM effect. However, it is unknown if attention influences CPM effects when the two are done in sequence., Methods: Healthy men (n = 25) underwent cuff algometry CPM-assessment where the pressure-pain detection and tolerance thresholds (PTT) were recorded on one leg with and without contralateral conditioning. Two identical sessions of four test stimuli equal to PTT (5 s, 1-min interval, scored on a visual analogue scale, VAS) with a painful conditioning from the second to the last test-stimulus were performed. Stroop sessions were followed by test stimuli with or without painful conditioning., Results: The VAS scores in the first two sessions showed excellent reliability (ICC = 0.92). VAS scores were lower in sessions with Stroop compared to sessions without Stroop (p = .05) indicating an analgesic effect of Stroop. Participants were subgrouped into CPM responders and CPM non-responders according to CPM effects in the first two sessions. CPM non-responders (n = 13) showed facilitation to repeated noxious stimuli in all sessions with no effect of conditioning or Stroop (p = .02)., Conclusion: Attention and CPM both modulate pain in healthy men. Attention-induced analgesia works in CPM non-responders. Results indicate that attention and CPM are not the same and that they do not demonstrate additive effects when applied in sequence., Significance: Pain sensitivity is reduced after an attention task in healthy men. The delayed effects from attention only have minor effects on Conditioned Pain Modulation (CPM), and results support that attention-driven analgesia works independently of CPM. Results indicate that individual strategies for pain inhibition exist and that an overlap between the mechanisms of CPM and selective attention is limited. Moreover, painful phasic stimuli may increase the number of healthy volunteers with negative CPM effects., (© 2019 European Pain Federation - EFIC®.)

Objective: To estimate the prevalence of Parkinson disease (PD) and Parkinson disease dementia (PDD) in community nursing homes. To estimate how many residents who meet criteria for PDD have been diagnosed with PDD and prescribed a Federal Drug Administration (FDA)-approved treatment for PDD., Setting: Three private Saint Louis metropolitan area nursing homes., Participants: Fifty-five residents with a chart diagnosis of PD from a total of 714 residents were identified. Sixteen subjects or families did not give consent and two were excluded from the study because advanced stage of the illness impaired evaluation. Thirty-seven subjects with an established diagnosis of PD participated in the study., Design and Measurements: A chart review was used to identify the study sample: residents with an established diagnosis of PD. Consent was obtained from the nursing home administration, families or guardians, and the residents themselves (where applicable). Study data were obtained from review of residents' medical charts, family/caregiver interview, resident interview, resident cognitive testing (Mini-Mental State Examination, clock drawing test), and resident depression assessment (15-item Geriatric Depression Scale). Diagnosis of PDD was defined using existing literature and described below. Data were analyzed using SPSS version 15., Result: Of the 714 nursing home residents, 55 (7.7%) met criteria for PD. Of these, 37 participated in the study and 18 (48.6%) met criteria for PDD. None were diagnosed with PDD in the charts and 11.1% (2 of 18) were on FDA-approved treatment., Conclusion: In this sample of nursing home residents, the prevalence of PD was 7.7% and the overall prevalence of PDD was 3.7%. PDD remains an unrecognized entity in the nursing home setting. Close to half (48.65%) of nursing home residents with PD may have PDD at any given time and they remain undiagnosed and largely undertreated., (Copyright © 2013 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

To explore the mechanism of horizontal transmission of hepatitis B virus (HBV) among children, we investigated the quantitative relationship between HBV in saliva and blood from 46 children with chronic hepatitis B. We found high levels of HBV DNA in saliva of HBeAg (+) children, suggesting saliva as a vehicle for horizontal transmission of HBV among children.