Search

Background National strategies from North America call for substantive improvements in entry-level pain management education to help reduce the burden of chronic pain. Past work has generated a valuable set of interprofessional pain management competencies to guide the education of future health professionals. However, there has been very limited work that has explored the development of such competencies for individual professions in different regions. Developing profession-specific competencies tailored to the local context is a necessary first step to integrate them within local regulatory systems. Our group is working toward this goal within the context of entry-level physiotherapy (PT) programs across Canada. Aims This study aimed to create a consensus-based competency profile for pain management, specific to the Canadian PT context. Methods A modified Delphi design was used to achieve consensus across Canadian university-based and clinical pain educators. Results Representatives from 14 entry-level PT programs (93% of Canadian programs) and six clinical educators were recruited. After two rounds, a total of 15 competencies reached the predetermined endorsement threshold (75%). Most participants (85%) reported being “very satisfied” with the process. Conclusions This process achieved consensus on a novel pain management competency profile specific to the Canadian PT context. The resulting profile delineates the necessary abilities required by physiotherapists to manage pain upon entry to practice. Participants were very satisfied with the process. This study also contributes to the emerging literature on integrated research in pain management by profiling research methodology that can be used to inform related work in other health professions and regions.

In this paper we describe the design, development and functionality of a haptic force-matching device. This device measures precise sensorimotor perception by determining a subject’s ability to successfully attenuate incoming sensory signals. Sensory attenuation provides a novel method of investigating psychophysical aspects of perception and may help to formulate neurocognitive models that may account for maladaptive interoceptive processing. Several similar custom-made devices have been reported in the literature; however, a clear description of the mechanical engineering necessary to build such a device is lacking. We present, in detail, the hardware and software necessary to build such a device. Subjects (N = 25) were asked to match a target force on their right index finger, first by pressing directly on their finger with their other hand, then by controlling the device through an external potentiometer to control the force (indirectly) though a torque motor. In the direct condition, we observed a consistent overestimation of the force reproduced; mean force error 0.50 newtons (standard error = 0.04). In the slider condition we observed a more accurate, yet small, underestimation of reproduced force: −0.30 newtons (standard error = 0.03).

OBJECTIVE The objective of the study was to explore and then validate the factor structure of the Pain Assessment Tool (PAT). MATERIALS AND METHODS A retrospective medical record review was performed of all infants who were admitted to a neonatal intensive care unit between 2008 and 2018 and had 1 PAT assessment (n=2111). Scores on items of the PAT were collected. Infants were randomized to either the principal component analysis (n=1100) to explore the factor structure or confirmatory factor analysis (n=1011). RESULTS Infants in the 2 samples were demographically comparable. A 2-factor model, consisting of factors Behavioral and Physiological Pain Measures, was extracted, explaining 39.8% of the total variance. There was a low interfactor correlation (r=0.12), and both Behavioral (r=0.59) and Physiological Pain (r=0.37) Measures factor scores were correlated with nurses' perception of pain scores. When the frequencies in the gestational age at birth categories were compared between upper and lower quartile score infants, there was more with pain at preterm than at term (χ2(3)=44.9, P

One barrier to optimal pain management in the neonatal intensive care unit (NICU) is how the healthcare community perceives, and therefore manages, neonatal pain. In this paper, we emphasise that healthcare professionals not only have a professional obligation to care for neonates in the NICU, but that these patients are intrinsically worthy of care. We discuss the conditions that make neonates worthy recipients of pain management by highlighting how neonates are (1) vulnerable to pain and harm, and (2) completely dependent on others for pain management. We argue for a relational account of ethical decision-making in the NICU by demonstrating how an increase in vulnerability and dependence may be experienced by the healthcare community and the neonate's family. Finally, an ethical framework for decisions around neonatal pain management is proposed, focussing on surrogate decision-making and the importance of compassionate action through both a reflective and an affective empathy. As empathy can be highly motivating against pain, we propose that, in addition to educational programs that raise awareness and knowledge of neonatal pain and pain management, healthcare professionals must cultivate empathy in a collective manner, where all members of the NICU team, including parents, are compassionate decision-makers.

OBJECTIVES Clinical guidelines recommend that health care providers assist children to understand their experience of persistent pain, with pain science education a key component of clinical management in pediatric pain clinics. Currently, no tool exists to assess a child's concept of pain. The aim of this study was to develop such a tool and to evaluate its psychometric properties. METHODS After a rigorous process to generate items, assess content validity, evaluate readability and understandability, and pretest items, a cohort of 124 children (aged 8 to 12 y) independently completed the measure on 2 occasions, along with additional measures of pain, function, and pain-related distress. RESULTS The resulting unidimensional 14-item Concept of Pain Inventory (COPI) had acceptable internal consistency (α= 0.78) and moderate test-retest reliability (intraclass correlation coefficient (3,1) = 0.55; 95% CI, 0.37-0.68). Higher COPI scores reflect greater alignment with contemporary pain science. COPI scores were inversely correlated with pain intensity and functional disability, but unrelated to pain catastrophizing and pain-related fear. At 1 to 2 months' follow-up, baseline COPI scores were inversely correlated with clinical variables of functional disability and pain intensity. DISCUSSION These results support the COPI as a brief, psychometrically sound tool to assess a child's concept of pain. Clinically, this tool may facilitate individualized pain science education to target identified conceptual "gaps" or misconceptions and to evaluate the effectiveness of pain science education in children. Further research examining its efficacy and impact is warranted.

BACKGROUND The aim of this study was (a) to statistically identify distinct trajectories of pain following surgery in infants less than 6 months of age, and (b) to compare these trajectories to descriptions of chronic pain in infants in the neonatal intensive care unit (NICU). METHODS This was a retrospective medical record review of infants admitted to a NICU between 2008 and 2018 following surgery. All infants who underwent one major procedure to the abdomen or thorax and returned to the NICU following surgery were included. Pain was assessed regularly using a validated Pain Assessment Tool. Group-based trajectory analysis was used to determine the trajectory of recovery from pain following surgery. RESULTS A total of 726 infants were included in the study. A two-group trajectory model, defined as typical and atypical pain trajectories, was selected. The typical group (n = 467) consisted of infants who had significantly fewer days (1.5 ± 2.3 vs 5.3 ± 5.5, p

Background and objective The aim of this study was to investigate prognostic factors for pain and functional disability in children and/or adolescents with persisting pain. Databases and data treatment To be included, studies had to be published, peer-reviewed prospective cohort studies of children and/or adolescents with persisting pain at baseline, that reported at least one baseline prognostic factor and its relationship with pain or functional disability at least 1 month after baseline. Two reviewers independently assessed study eligibility, completed data extraction and undertook quality assessment. Meta-analyses were performed when a prognostic factor was reported in two or more studies. Results Of 10,992 studies identified from electronic database searches, 18 were included, investigating 62 potential prognostic factors. In clinical settings, insufficient data were available for meta-analysis. Some positive associations with pain and/or disability were reported by single studies for older age, baseline pain intensity and baseline functional disability across multiple combinations of follow-up times and outcomes. In community settings, meta-analyses of two studies found that prognostic factors for the ongoing presence of pain at medium-term (1-year) follow-up were older age (OR 1.25; 95% CI = 1.05-1.47), weekly day tiredness (OR 1.69; 95% CI = 1.14-2.51), weekly abdominal pain (OR 1.44; 95% CI = 1.03-2.02) and waking during the night (OR 1.49; 95% CI = 1.05-2.13). No studies in community settings reported on prognostic factors for functional disability. Conclusions Prognostic factors having significant associations with future pain and disability were identified; however, as few were investigated in more than one comparable study, the results need to be interpreted with caution. Significance Prognostic factors from across the biopsychosocial spectrum are important to consider in paediatric pain clinical practice. However, most prognostic factors that experts have previously agreed upon have not been assessed in prospective cohort studies to date. The findings may help with prioritising data to collect during clinical assessments of children presenting with pain, in the context of pain and functional disability outcomes.

OBJECTIVES Assessing knowledge and beliefs regarding pain science can identify gaps and misconceptions. The Concept of Pain Inventory (COPI) was recently developed in children with the intent to guide targeted pain science education. We utilized the original COPI item pool to (1) develop a tool to assess an adult's concept of pain in a cohort who had not received pain science education, (2) evaluate its psychometric properties, (3) examine distribution of scores in a cohort of adults who had received pain science education, and (4) examine associations between scores and clinical variables. MATERIALS AND METHODS A total cohort of 627 adults were recruited through social media for an online survey. Initial development was conducted on those who had not received prior pain science education (n=125), then the COPI-Adult tool was tested in those who had received prior pain science education (n=502). RESULTS The resulting unidimensional 13-item COPI-Adult had acceptable internal consistency (α=0.78) and good test-retest reliability at 1 week (Intraclass Correlation Coefficient3,1=0.84 (95% confidence interval: 0.71-0.91). Higher COPI-Adult scores reflect greater alignment with contemporary pain science. COPI-Adult scores were correlated with revised Neurophysiology of Pain Questionnaire (rNPQ) scores and inversely correlated with average and current pain intensity, and pain interference. Adults who reported having received pain science education had significantly higher mean COPI-Adult scores than those who had not, and this difference exceeded the smallest detectable change. DISCUSSION The COPI-Adult is a brief questionnaire with promising psychometric properties to identify conceptual gaps or misconceptions to inform individualized pain science education.

BACKGROUND An individual's drive to seek medical help remains a complex behavioural process, incorporating psychological, social and symptom-specific factors. Within irritable bowel syndrome (IBS), gastrointestinal symptoms only predict a small portion of the high healthcare-seeking experienced. AIM To examine the moderating role of quality of life (QoL) domains on this relationship to help explain the variance observed. METHODS This is an analysis of a Swedish population-based prospective study of healthcare use over a 12-year period. At baseline, gastrointestinal symptoms were measured with the valid Gastrointestinal Symptom Rating Scale, and QoL via the SF-36. 1159 subjects (57% female; mean age 48.6 years) had their health records matched with the initial survey. 164 were classified as IBS by Rome II criteria. Negative binomial or logistic models were fit to evaluate the moderating effect of particular QoL domains on the relationship between gastrointestinal symptoms and prospective healthcare utilisation. RESULTS Gastrointestinal symptoms were associated with prospective healthcare use, but moderation in this relationship by particular QoL domains was not supported; most models did not reach statistical significance. Furthermore, the impact of IBS status did not alter the moderation hypotheses. CONCLUSIONS Particular QoL domains did not impact the relationship between gastrointestinal symptoms on prospective healthcare seeking. Future research should continue to examine other psychological, social and symptom variables to identify predictors of high healthcare consumers in IBS.

Background Low back pain is the leading worldwide cause of years lost to disability and the problem is worsening. This paper describes and demonstrates the scholarly development and contextual refinement of a primary care program for acute low back pain in Sydney, Australia. Methods Hybrid theoretical frameworks were applied, and co-design was used to contextualise the program to the local healthcare setting. Results The program was developed in four stages. In stage 1, the scientific evidence about management of acute low back pain in primary care was examined. In stage 2, stakeholders (patients and clinicians) were consulted in nationwide surveys. Data from stages 1 and 2 were used to design an initial version of the program, called My Back My Plan. Stage 3 involved the contextual refinement of the program to the local setting, MQ Health Primary Care. This was achieved by co-design with primary care clinicians and patients who had sought care for low back pain at MQ Health Primary Care clinics. In stage 4, a panel of Australian experts on clinical care for low back pain reviewed the contextualised version of My Back My Plan and final amendments were made. Conclusion My Back My Plan has been developed using an innovative scholarly approach to intervention development.

Background Low back pain is the largest cause of years lived with a disability in Australia, and there is an urgent need for innovations to address global gaps between evidence and practice. Methods This study was a phase 1, single-group, pre–post pilot trial of My Back My Plan, a primary care program for acute low back pain. The trial was conducted at MQ Health Primary Care at Macquarie University in Sydney, Australia. The primary outcomes were feasibility and acceptability. Results Fourteen participants were recruited to the study, with 79% and 93% followed up at 1 and 3 months respectively. Ten general practitioners and four physiotherapists at MQ Health Primary Care delivered the intervention. Although the rate of patient recruitment to the trial was low, other aspects of feasibility (such as intervention adherence and safety) were high. Participating clinicians reported that the program was useful for patients, and the majority stated that the program facilitated person-centred care. Patients rated My Back My Plan as highly acceptable, indicating that they had a better understanding of their low back pain, they were given personalised care and were more confident in self-managing their low back pain. At the 3 month follow-up, 85% of participants stated they were very likely to recommend the program to others. Conclusions This study suggests that the co-designed, contextually refined MBMP program for MQ Health Primary Care is acceptable to people with acute onset low back pain and warrants further evaluation.

Objectives To determine whether pain-related treatment outcomes, following an online Cognitive Behavioural Therapy (CBT) intervention for chronic pain, were moderated by the pain etiology of a medically explained or unexplained origin. Methods Data were available from 471 participants who completed the online pain management program between March 2013 and August 2014. Participants' pain symptoms were classified as being medically explained symptoms (MES: n = 292) or medically unexplained symptoms (MUS: n = 222) via analysis of clinical data. Outcome variables were pain-related disability, average pain intensity, depression and anxiety. Results Moderation analyses were non-significant for all dependent variables. Between group differences (CBT and control) were larger for depression in those classified with MES, compared with MUS (MUS: mean change = −3.50 [95% CI = −4.98 to −2.22]; MES: mean change = −5.72 [95% CI = −7.49 to −4.09]). However, between group differences were small for pain intensity (MUS: mean change = −0.03 [95% CI = −0.83 to 0.81]; MES: mean difference = −1.12 [95% CI = −1.84 to 0.40]). Conclusion The therapeutic outcomes examined in this study associated with an online CBT program do not appear to be altered by whether the participants' pain symptoms are medically explained or unexplained.

One barrier to optimal pain management in the neonatal intensive care unit (NICU) is how the healthcare community perceives, and therefore manages, neonatal pain. In this paper, we emphasise that healthcare professionals not only have a professional obligation to care for neonates in the NICU, but that these patients are intrinsically worthy of care. We discuss the conditions that make neonates worthy recipients of pain management by highlighting how neonates are (1) vulnerable to pain and harm, and (2) completely dependent on others for pain management. We argue for a relational account of ethical decision-making in the NICU by demonstrating how an increase in vulnerability and dependence may be experienced by the healthcare community and the neonate's family. Finally, an ethical framework for decisions around neonatal pain management is proposed, focussing on surrogate decision-making and the importance of compassionate action through both a reflective and an affective empathy. As empathy can be highly motivating against pain, we propose that, in addition to educational programs that raise awareness and knowledge of neonatal pain and pain management, healthcare professionals must cultivate empathy in a collective manner, where all members of the NICU team, including parents, are compassionate decision-makers.

BACKGROUND AND PURPOSE: The clinical importance of lumbar MR imaging findings is unclear. This study was an exploratory investigation of whether lumbar spine MR imaging findings change more commonly during a 12-week period in individuals with acute low back pain compared with pain-free controls. MATERIALS AND METHODS: Twenty individuals with recent-onset low back pain and 10 pain-free controls were recruited into an exploratory prospective cohort study. All participants had a lumbar spine MR imaging at baseline and repeat MR imaging scans at 1, 2, 6, and 12 weeks. The proportion of individuals who had MR imaging findings that changed during the 12-week period was compared with the same proportion in the controls. RESULTS: In 85% of subjects, we identified a change in at least 1 MR imaging finding during the 12 weeks; however, the proportion was similar in the controls (80%). A change in disc herniation, annular fissure, and nerve root compromise was reported more than twice as commonly in the subjects as in controls (65% versus 30%, 25% versus 10%, and 15% versus 0%, respectively). Caution is required in interpreting these findings due to wide confidence intervals, including no statistical difference. For all other MR imaging findings, the proportions of subjects and controls in whom MR imaging findings were reported to change during 12 weeks were similar. CONCLUSIONS: Changes in MR imaging findings were observed in a similar proportion of the low back pain and control groups, except for herniations, annular fissures, and nerve root compromise, which were twice as common in subjects with low back pain.

Pain is common, but often poorly managed after breast cancer treatment. Screening questionnaires and the Neuropathic Pain Special Interest Group (NeuPSIG) criteria are 2 clinical approaches used to determine whether pain has neuropathic components, which may enable better pain management. The aims of this review were (1) to synthesise data from the literature on neuropathic pain prevalence in women after breast cancer treatment; (2) to investigate whether the prevalence of neuropathic pain differed between studies using screening questionnaires and the NeuPSIG criteria. We searched for studies that administered a validated neuropathic pain screening questionnaire and/or the NeuPSIG criteria to women treated for early-stage (I-III) breast cancer. Thirteen studies using screening questionnaires (N = 3792) and 3 studies using components of the NeuPSIG criteria (N = 621) were included. Meta-analyses were conducted for questionnaire data but not for NeuPSIG criteria data because of inadequate homogeneity. Among all participants treated for early-stage breast cancer, pooled prevalence estimates (95% confidence interval) ranged between 14.2% (8.3-21.4) and 27.2% (24.7-88.4) for studies using screening questionnaires; studies using NeuPSIG criteria reported prevalence rates from 24.1% to 31.3%. Among those who reported pain after treatment, the pooled prevalence estimate (95% confidence interval) of neuropathic pain from screening questionnaires ranged from 32.6% (24.2-41.6) to 58.2% (24.7-88.4); studies using NeuPSIG criteria reported prevalence rates from 29.5% to 57.1%. These prevalence estimates are higher than those reported for other types of cancer, and emphasise the need to assess the contribution of neuropathic pain after breast cancer treatment. Trial registration PROSPERO registration CRD42015029987.

Systematic review OBJECTIVE.: The aim of the study was to investigate whether magnetic resonance imaging (MRI) findings change over a relatively short period of time (

Quantitative sensory tests (QSTs) have been increasingly used to investigate alterations in somatosensory function in a wide range of painful conditions. The interpretation of these findings is based on the assumption that the measures are stable and reproducible. To date, reliability of QST has been investigated for short test-retest intervals. The aim of this study was to investigate the long-term reliability of a multimodal QST assessment in healthy people, with testing conducted on 3 occasions over 4 months. Forty-two healthy people were enrolled in the study. Static and dynamic tests were performed, including cold and heat pain threshold (CPT, HPT), mechanical wind-up [wind-up ratio (WUR)], pressure pain threshold (PPT), 2-point discrimination (TPD), and conditioned pain modulation (CPM). Systematic bias, relative reliability and agreement were analysed using repeated measure analysis of variance, intraclass correlation coefficients (ICCs3,1) and SE of the measurement (SEM), respectively. Static QST (CPT, HPT, PPT, and TPD) showed good-to-excellent reliability (ICCs: 0.68-0.90). Dynamic QST (WUR and CPM) showed poor-to-good reliability (ICCs: 0.35-0.61). A significant linear decrease over time was observed for mechanical QST at the back (PPT and TPD) and for CPM (P < 0.01). Static QST were stable over a period of 4 months; however, a small systematic decrease over time has been observed for mechanical QST. Dynamic QST showed considerable variability over time; in particular, CPM using PPT as the test stimulus did not show adequate reliability, suggesting that this test paradigm may be less useful for monitoring individuals over time.

ObjectiveA person’s concept of pain can be defined as how they understand what pain actually is, what function it serves and what biological processes are thought to underpin it. This study aimed to explore the concept of pain in children with and without persistent pain.DesignIn-depth, face-to-face interviews with drawing tasks were conducted with 16 children (aged 8–12 years) in New South Wales, Australia. Thematic analysis was used to analyse and synthesise the data.SettingChildren with persistent pain were identified from a pain clinic waiting list in Australia, and children without pain were identified through advertising flyers and email bulletins at a university and hospital.ParticipantsEight children had persistent pain and eight children were pain free.ResultsFour themes emerged from the data: ‘my pain-related knowledge’, ‘pain in the world around me’, ‘pain in me’ and ‘communicating my concept of pain’. A conceptual framework of the potential interactions between the themes resulting from the analysis is proposed. The concept of pain of Australian children aged 8–12 years varied depending on their knowledge, experiences and literacy levels. For example, when undertaking a drawing task, children with persistent pain tended to draw emotional elements to describe pain, whereas children who were pain free did not.ConclusionsGaining an in-depth understanding of a child’s previous pain-related experiences and knowledge is important to facilitate clear and meaningful pain science education. The use of age-appropriate language, in combination with appropriate assessment and education tasks such as drawing and discussing vignettes, allowed children to communicate their individual concept of pain.

This systematic review summarises evidence assessing endogenous pain inhibition in people with irritable bowel syndrome (IBS) compared with healthy controls using conditioned pain modulation (CPM) and offset analgesia (OA). Evidence regarding the role of psychological variables is also examined. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Four electronic databases were searched to retrieve studies assessing CPM or OA in adults diagnosed with IBS according to the ROME II/III criteria. Standardized mean differences were calculated for each study and a random effects model was used for meta-analysis. Eleven studies were included, 5 of which reported results on the relationship between CPM and psychological variables. None of the studies assessed OA. The risk of bias assessment found a lack of assessor blinding in all studies. The pooled effect estimate was 0.90 (95% CI, 0.40-1.40) indicating a significantly lower CPM effect in people with IBS compared with controls. This effect was reduced to 0.51 when 1 outlier was excluded from the analysis. In addition, reduced CPM responses were significantly correlated with higher anxiety (r=0.17 to 0.64), stress (r=0.63), and pain catastrophizing (r=0.38) in people with IBS; however, the evidence available was limited and the strength of these associations variable. Depression was not found to be associated with CPM in these IBS cohorts. The results of this review suggest that people with IBS, as a group, demonstrate reduced pain inhibition measured by CPM. The preliminary evidence about the association between psychological factors and CPM warrants further investigations.

© 2018 2018 American Medical Association. All rights reserved. Importance: Many patients with acute low back pain do not recover with basic first-line care (advice, reassurance, and simple analgesia, if necessary). It is unclear whether intensive patient education improves clinical outcomes for those patients already receiving first-line care. Objective: To determine the effectiveness of intensive patient education for patients with acute low back pain. Design, Setting, and Participants: This randomized, placebo-controlled clinical trial recruited patients from general practices, physiotherapy clinics, and a research center in Sydney, Australia, between September 10, 2013, and December 2, 2015. Trial follow-up was completed in December 17, 2016. Primary care practitioners invited 618 patients presenting with acute low back pain to participate. Researchers excluded 416 potential participants. All of the 202 eligible participants had low back pain of fewer than 6 weeks' duration and a high risk of developing chronic low back pain according to Predicting the Inception of Chronic Pain (PICKUP) Tool, a validated prognostic model. Participants were randomized in a 1:1 ratio to either patient education or placebo patient education. Interventions: All participants received recommended first-line care for acute low back pain from their usual practitioner. Participants received additional 2 × 1-hour sessions of patient education (information on pain and biopsychosocial contributors plus self-management techniques, such as remaining active and pacing) or placebo patient education (active listening, without information or advice). Main Outcomes and Measures: The primary outcome was pain intensity (11-point numeric rating scale) at 3 months. Secondary outcomes included disability (24-point Roland Morris Disability Questionnaire) at 1 week, and at 3, 6, and 12 months. Results: Of 202 participants randomized for the trial, the mean (SD) age of participants was 45 (14.5) years and 103 (51.0%) were female. Retention rates were greater than 90% at all time points. Intensive patient education was not more effective than placebo patient education at reducing pain intensity (3-month mean [SD] pain intensity: 2.1 [2.4] vs 2.4 [2.2]; mean difference at 3 months, -0.3 [95% CI, -1.0 to 0.3]). There was a small effect of intensive patient education on the secondary outcome of disability at 1 week (mean difference, -1.6 points on a 24-point scale [95% CI, -3.1 to -0.1]) and 3 months (mean difference, -1.7 points, [95% CI, -3.2 to -0.2]) but not at 6 or 12 months. Conclusions and Relevance: Adding 2 hours of patient education to recommended first-line care for patients with acute low back pain did not improve pain outcomes. Clinical guideline recommendations to provide complex and intensive support to high-risk patients with acute low back pain may have been premature. Trial Registration: Australian Clinical Trial Registration Number: 12612001180808.

Quantitative sensory testing (QST) measures have recently been shown to predict outcomes in various musculoskeletal and pain conditions. The aim of this systematic review was to summarize the emerging body of evidence investigating the prognostic value of QST measures in people with low back pain (LBP). The protocol for this review was prospectively registered on the International Prospective Register of Systematic Reviews. An electronic search of six databases was conducted from inception to October 2015. Experts in the field were contacted to retrieve additional unpublished data. Studies were included if they were prospective longitudinal in design, assessed at least one QST measure in people with LBP, assessed LBP status at follow-up, and reported the association of QST data with LBP status at follow-up. Statistical pooling of results was not possible due to heterogeneity between studies. Of 6,408 references screened after duplicates removed, three studies were finally included. None of them reported a significant association between the QST measures assessed and the LBP outcome. Three areas at high risk of bias were identified which potentially compromise the validity of these results. Due to the paucity of available studies and the methodological shortcomings identified, it remains unknown whether QST measures are predictive of outcome in LBP.

Maladaptive responses to pain-related distress, such as pain catastrophizing, amplify the impairments associated with chronic pain. Many of these aspects of chronic pain are similar to affective distress in clinical anxiety disorders. In light of the role of the amygdala in pain and affective distress, disruption of amygdalar functional connectivity in anxiety states, and its implication in the response to noxious stimuli, we investigated amygdala functional connectivity in 17 patients with chronic low back pain and 17 healthy comparison subjects, with respect to normal targets of amygdala subregions (basolateral vs centromedial nuclei), and connectivity to large-scale cognitive–emotional networks, including the default mode network, central executive network, and salience network. We found that patients with chronic pain had exaggerated and abnormal amygdala connectivity with central executive network, which was most exaggerated in patients with the greatest pain catastrophizing. We also found that the normally basolateral-predominant amygdala connectivity to the default mode network was blunted in patients with chronic pain. Our results therefore highlight the importance of the amygdala and its network-level interaction with large-scale cognitive/affective cortical networks in chronic pain, and help link the neurobiological mechanisms of cognitive theories for pain with other clinical states of affective distress.

Background & Aims There is controversy about whether psychological factors (anxiety and depression) increase health care seeking by patients with irritable bowel syndrome (IBS). We investigated whether psychological factors increase health care seeking by patients with IBS and the effects of extragastrointestinal (extra-GI) symptoms. Methods We performed a population-based prospective study of health care use over a 12-year period in Sweden. From 2002 through 2006, 1244 subjects were selected randomly for an examination by a gastroenterologist and to complete questionnaires, including the Rome II modular questionnaire. Psychological factors were measured with the valid Hospital Anxiety and Depression scale and extra-GI symptoms were measured with a symptom checklist. Responses from 1159 subjects (57% female; mean age, 48.65 y) were matched with health records in 2016 (164 were classified as having IBS based on Rome II criteria). Results The overall association between depression or anxiety and health care use varied in subjects with and without IBS at baseline. The presence of extra-GI symptoms strengthened the relationship between anxiety and depression and prospective psychiatric visits for subjects with IBS and without IBS (incidence rate ratio, 1.14–1.26). Extra-GI symptoms did not alter the association of anxiety or depression with use of GI or extra-GI health care. Conclusions In a population-based study in Sweden, we found that individuals with high baseline anxiety or depression were more likely to seek psychiatric health care, but not GI or extra-GI health care, in the presence of extra-GI symptoms at baseline. Patients with IBS might benefit from more thorough assessments that examine extra-GI and psychological symptoms, to reduce health care utilization.

© 2018 World Institute of Pain Background: Pain education is an important part of multidisciplinary management of chronic pain. The characteristics of people likely to have more improvement in pain biology knowledge following pain education are unknown. Objective: To identify the baseline factors predicting changes in pain biology knowledge in adults with chronic pain following a 2-hour multidisciplinary pain education session. Methods: Fifty-five adults with chronic pain attended a 2-hour pain education session prior to a multidisciplinary assessment at a pain clinic. Patients completed the 12-item revised Neurophysiology of Pain Questionnaire (rNPQ, score/12) before and after the pain education session. The primary outcome was change in pain biology knowledge, evaluated with the change in rNPQ score. Ten preselected predictors were investigated using univariate models followed by multivariable models with a manual forwards-building process. Results: Education level and age were significantly associated with change in rNPQ score in the univariate models. Participants with higher levels of education had, on average, 1.96 (0.68 to 3.23) points more improvement in rNPQ score than those with lower levels of education. For every 10 years older a participant was, his or her rNPQ score changed on average by 0.5 (0.1 to 0.8) points less. In the multivariable model, only the education level remained significant, explaining 17% of the variance (R 2 = 0.17). The clinical variables that were assessed (pain severity, pain interference, pain self-efficacy, depression, anxiety, and pain catastrophizing) did not predict any knowledge change. Conclusion: This study suggests that, of those patients with chronic pain who choose to attend pain education, more educated patients are more likely to improve their pain biology knowledge after a pain education session.

Objectives The objective of the present study was to test the moderating impact of an unknown pain etiology on the relationship between psychological factors and chronic pain intensity and disability. Methods N = 471 chronic pain sufferers presented to an online Cognitive Behavioral Therapy randomized control trial, known as the Pain Course. Participants' etiology was classified as medically unexplained or medically explained via interview and self-reported data. Standardized psychological measures at baseline were used in a non-hierarchical cluster analysis, which allocated chronic pain participants into mutually exclusive groups. Results Four distinct clusters were identified: Psychologically healthy, mild psychological distress, high psychological distress, and average. The profile with high psychological distress experienced the greatest pain intensity (mean: 6.44 (SD = 1.66)) and disability (mean: 17.53 (SD: 3.65)). This relationship was not moderated by preceding pain etiology being medically explained or unexplained (χ2 (3) = 0.45, p = 0.93 and χ2 (3) = 7.07, p = 0.07 respectively). Conclusion These findings indicate that an unknown pain etiology has little role in altering the relationship between psychological factors and pain disability in individuals experiencing chronic pain. This suggests that the psychological association with pain disability and intensity experienced by people with medically unexplained symptoms is similar to people with medically explained symptoms.

Using the vibrating probe, we measured the extracellular current pattern around 4-day-old pea (Pisum sativum L. var. Greenfeast) root tips. Currents of 1.0 µA cm-2 flow into the meristematic and elongating tip, and smaller currents (0.1 µA cm-2) leave the mature zone basipetally behind this region. Wounding the root 3 mm from the root tip causes a very large (10 µA cm-2) inward current at the wound site. This disrupts the normal extracellular current pattern around the root. This wound current is inhibitable, and we present evidence that H+, and particularly Ca2+, may be involved. The time course of these ionic current changes is described. We propose that this wound current plays a role in the establishment of a new polarity in the cortical cells adjacent to a wound in root tissue. Possible mechanisms are discussed.

No abstract

Low back pain (LBP) is the highest cause of years lived with a disability in Australia and the most frequent musculoskeletal condition for which patients seek primary care. The aims of this study were to: (1) evaluate the current practices and perspectives of Australian GPs and physiotherapists managing acute back pain; and (2) explore alignment of care with clinical guidelines. This was a prospective cross-sectional Internet survey conducted from March 2018 to May 2018 of experienced Australian GPs and physiotherapists. Descriptive statistics were used to analyse all quantitative outcomes. Two hundred primary care practitioners (72% physiotherapists and 28% GPs) from all States and Territories of Australia completed the survey. Most primary care practitioners were familiar with clinical guidelines for acute back pain management and reported delivery of many of the core components of guideline-based care, including education, advice about favourable prognosis, encouraging activity and self-management and discouraging prolonged bed rest. Deviations from guideline-based care were common, including provision of analgesic medication, passive therapies and using radiological imaging. Australian primary care clinicians in this sample were aware of back pain guidelines and typically implement care that is consistent with guideline-based recommendations. Divergences from these guidelines may indicate that primary care practitioners are delivering evidence-based and person-centred care that integrates clinicians’ judgement with patients’ preferences and guideline-based evidence.

Background: This study aimed to investigate whether the addition of visceral manipulation, to a standard physiotherapy algorithm, improved outcomes in patients with low back pain. Methods: Sixty-four patients with low back pain who presented for treatment at a private physiotherapy clinic were randomized to one of two groups: standard physiotherapy plus visceral manipulation (n = 32) or standard physiotherapy plus placebo visceral manipulation (n = 32). The primary outcome was pain (measured with the 0–10 Numerical Pain Rating Scale) at 6 weeks. Secondary outcomes were pain at 2 and 52 weeks, disability (measured with the Roland-Morris Disability Questionnaire) at 2, 6 and 52 weeks and function (measured with the Patient-Specific Functional Scale) at 2, 6 and 52 weeks. This trial was registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12611000757910). Results: The addition of visceral manipulation did not affect the primary outcome of pain at 6 weeks (�0.12, 95% CI = �1.45 to 1.21). There were no significant between-group differences for the secondary outcomes of pain at 2 weeks or disability and function at 2, 6 or 52 weeks. The group receiving addition of visceral manipulation had less pain than the placebo group at 52 weeks (mean 1.57, 95% CI = 0.32 to 2.82). Participants were adequately blinded to group status and there were no adverse effects reported in either group. Conclusions: Our study suggests that visceral manipulation in addition to standard care is not effective in changing short-term outcomes but may produce clinically worthwhile improvements in pain at 1 year.

This study investigated the bidirectional relationship between the intensity of low back pain (LBP) and sleep disturbance. Further, the study aimed to determine whether any relationship is dependent on pain duration, symptoms of depression and anxiety, and the method of sleep assessment (subjective vs. objective).Eighty patients with LBP completed a sleep diary. A subgroup of 50 patients additionally wore an electronic device (Armband) to measure sleep for 7 consecutive days. Pain intensity was assessed twice daily using a sleep diary. Depression and anxiety symptoms were assessed at baseline using the Depression Anxiety Stress Scale questionnaire. Generalized estimating equations (GEE) with an exchangeable correlation structure were used to examine the relationship between day-time pain intensity and sleep.The GEE analysis showed that a night of poor sleep quality, difficulty falling sleep (assessed by the sleep diary), waking after sleep onset, and low sleep efficiency (assessed by the sleep diary and Armband) were followed by a day with higher pain intensity. Further, a day with higher pain intensity was associated with a decrease in the subsequent night's sleep quality, an increase in sleep latency (assessed by the sleep diary), waking after sleep onset (assessed by both measures), and low sleep efficiency (assessed by the Armband).The findings demonstrate that there is a bidirectional relationship between sleep and pain intensity in patients with LBP. The relationship is independent of pain duration and baseline symptoms of depression and anxiety and somewhat dependent on the method of sleep measurement (sleep diary or Armband). Future research is needed to determine whether targeting sleep improvement in patients with LBP contributes to pain reduction.

Patient characteristics associated with the course and severity of low back pain (LBP) and disability have been the focus of extensive research, however, known characteristics do not explain much of the variance in outcomes. The relationship between anterior trunk pain (ATP) and LBP has not been explored, though mechanisms for visceral referred pain have been described. Study objectives were: (1) determine prevalence of ATP in chronic LBP patients, (2) determine whether ATP is associated with increased pain and disability in these patients, and (3) evaluate whether ATP predicts the course of pain and disability in these patients. In this study, spinal outpatient department patients mapped the distribution of their pain and patients describing pain in their chest, abdomen or groin were classified with ATP. Generalized estimating equations were performed to investigate the relationship between ATP and LBP outcomes. A total of 2974 patients were included and 19.6% of patients reported ATP. At all time points, there were significant differences in absolute pain intensity and disability in those with ATP compared with those without. The presence of ATP did not affect the clinical course of LBP outcomes. The results of this study suggest that patients who present with LBP and ATP have higher pain and disability levels than patients with localised LBP. Visceral referred pain mechanisms may help to explain some of this difference.

Objective Recent research suggests that sleep quality and pain intensity are intimately linked. Although sleep problems are common in patients with low back pain, the effect of sleep quality on the levels of pain intensity is currently unknown. The aim of this study was to investigate the effect of sleep quality on subsequent pain intensity in patients with recent-onset low back pain. Methods Data on 1,246 patients with acute low back pain were included in the analysis. Sleep quality was assessed using the sleep quality item of the Pittsburgh Sleep Quality Index, scored on a 0–3-point scale, where 0 = very good sleep quality and 3 = very bad sleep quality. Pain intensity was assessed on a numerical rating scale (range 0–10). A generalized estimating equation (GEE) analysis modeled with an exchangeable correlation structure was used to examine the relationship between sleep quality and pain intensity. The model further controlled for symptoms of depression and prognostic factors for low back pain. Results The GEE analysis demonstrated a large effect of poor sleep on subsequent pain intensity, such that for every 1-point decrease in sleep quality (based on a 0–3-point scale), pain intensity (based on a 0–10-point scale) increased by 2.08 points (95% confidence interval 1.99−2.16). This effect was independent of depression and common prognostic factors for low back pain. Conclusion Sleep quality is strongly related to subsequent pain intensity in patients with acute low back pain. Future research is needed to determine whether targeting sleep improvement contributes to pain reduction.

Objective To investigate whether kinesiotaping improves excessive foot pronation compared with sham kinesiotaping. Design Quasi-randomised, double-blind study. Setting One primary care centre. Participants One hundred and thirty participants were screened for inclusion. Sixty-eight participants with pronated feet [Foot Posture Index (FPI)≥6] were enrolled, and the follow-up rate was 100%. Interventions Participants were allocated into one of two groups: an experimental kinesiotaping group (KT1) and a sham taping group (KT2). Measures were collected by a blinded assessor at baseline, and 1minute, 10minutes, 60minutes and 24hours after taping. Main outcome measures The primary outcome was total FPI score, and the secondary outcome was rear-foot FPI score. Results There were no significant differences in total FPI score between kinesiotaping and sham taping at any time point. Similarly, there were no significant differences in rear-foot FPI score, apart from at 60-minute follow-up when the difference between groups was significant ( P =0.04) but the effect size was very small (0.85 points on the rear-foot FPI score between −6 and +6). Conclusions Kinesiotaping does not correct foot pronation compared with sham kinesiotaping in people with pronated feet.

Supplemental Digital Content is Available in the Text., Introduction: There is a knowledge gap about the current experiences and needs of people with low back pain (LBP) seeking primary care in Australia. Objectives: The aim of this study was to understand the experiences and needs of Australians who have received treatment for LBP in primary care. Methods: This was a prospective, cross-sectional internet survey conducted between July 2017 and September 2017. Participants were adults who had experienced an episode of LBP in the past year, had sought primary care in Australia, and were proficient in English. Outcomes were patient-reported experiences about primary care treatment, including reasons for seeking care, health care practitioners consulted, components of care received, and patients' evaluations of the importance and helpfulness of treatment. Results: A total of 426 Australians completed the survey. The response rate of survey completion was 50%. Participants reported seeking primary care for LBP not only for pain relief, but for difficulties with activities and participation with usual social roles as well as quality of life and mood. Participants consulted multiple health care practitioners and used numerous treatment modalities. Only half reported they received education and a very low proportion were aware of receiving guideline-based advice. The level of satisfaction with care was below moderate for 42% of respondents. Participants reported that they want LBP care to be more person-centred and better tailored to their needs; they also reported wanting more education, particularly about prevention of future episodes and self-management. Conclusions: The needs of people currently seeking primary care for LBP in Australia do not seem to be adequately met. Improving patients' experiences and outcomes may require better integration of health care across providers and delivery of more person-centred care.

Objectives: The first aim of this study was to investigate whether kinesiotaping (KT) can increase the acromiohumeral distance (AHD) in asymptomatic subjects in the short term. The second aim was to investigate whether the direction of kinesiotaping application influences AHD. Background: In recent years, the use of KT has become increasingly popular for a range of musculoskeletal conditions and for sport injuries. To date, we are unaware of any research investigating the effect of kinesiotaping on AHD. Moreover, it is unknown whether the direction of kinesiotaping application for the shoulder is important. Methods: Forty nine participants were randomly assigned to one of three groups: kinesiotaping group 1 (KT1), kinesiotaping group 2 (KT2) and sham kinesiotaping (KT3). AHD ultrasound measurements at 0 � and 60� of shoulder elevation were collected at baseline and immediately after kinesiotape application. Results: The results showed significant improvements in AHD after kinesiotaping, compared with sham taping. The mean difference in AHD between KT1 and KT3 groups was 1.28 mm (95% CI: 0.55, 2.03), and between KT2 and KT3 was 0.98 mm (95% CI: 0.23, 1.74). Comparison of KT1 and KT2 groups, which was performed to identify whether the direction of taping influences the AHD, indicated there were no significant differences. Conclusion: KT increases AHD in healthy individuals immediately following application, compared with sham kinesiotape. No differences were found with respect to the direction in which KT was applied. 2013 Elsevier Ltd. All rights reserved. 1. Background

OBJECTIVES: To determine predictors of satisfaction with care and symptoms in patients with acute low back pain 1 year after presentation to primary care.METHODS: The study is a secondary analysis of an existing cohort study of 1343 patients with acute low back pain presenting to primary care. Participants presenting to general practitioners, physiotherapists, or chiropractors were assessed at the initial consultation and followed up over 12 months. Putative predictors of patient satisfaction were extracted from baseline questionnaires. Multivariate logistic regression models were developed to predict satisfaction with care and satisfaction with symptoms at the 12-month follow-up.RESULTS: Most patients were highly satisfied with the care received (76%) and a smaller proportion with their symptoms (55%) at 12 months. Pain intensity at 12 months had a strong association with both measures of satisfaction. After controlling for the level of pain intensity, those born outside Australia, older people, and those reporting more symptoms of depression were less likely to be satisfied with the care received. Patients reporting poor general health at the initial visit and more symptoms of depression were less likely to be satisfied with their symptoms at the 12-month follow-up.DISCUSSION: Pain intensity at the 12-month follow-up has a strong association with patient satisfaction. Primary care practitioners should remain aware of the influence of cultural, demographic, and psychological factors on satisfaction with care and symptoms.

Highlights • Patient education is recommended in the primary care management of acute low back pain. • The PREVENT Trial is the first placebo-controlled randomized trial to evaluate the efficacy of patient education. • Statistical analysis plans increase the transparency around how researchers plan to estimate and interpret treatment effects from randomized trials. • This protocol describes the pre-specified principles, methods, and procedures to be adhered to in the statistical analysis of the PREVENT trial data., Background Statistical analysis plans increase the transparency of decisions made in the analysis of clinical trial results. The purpose of this paper is to detail the planned analyses for the PREVENT trial, a randomized, placebo-controlled trial of patient education for acute low back pain. Results We report the pre-specified principles, methods, and procedures to be adhered to in the main analysis of the PREVENT trial data. The primary outcome analysis will be based on Mixed Models for Repeated Measures (MMRM), which can test treatment effects at specific time points, and the assumptions of this analysis are outlined. We also outline the treatment of secondary outcomes and planned sensitivity analyses. We provide decisions regarding the treatment of missing data, handling of descriptive and process measure data, and blinded review procedures. Conclusions Making public the pre-specified statistical analysis plan for the PREVENT trial minimizes the potential for bias in the analysis of trial data, and in the interpretation and reporting of trial results. Trial registration ACTRN12612001180808 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12612001180808)

Chronic low back pain (cLBP) has a tremendous personal and socioeconomic impact, yet the underlying pathology remains a mystery in the majority of cases. An objective measure of this condition, that augments self-report of pain, could have profound implications for diagnostic characterization and therapeutic development. Contemporary research indicates that cLBP is associated with abnormal brain structure and function. Multivariate analyses have shown potential to detect a number of neurological diseases based on structural neuroimaging. Therefore, we aimed to empirically evaluate such an approach in the detection of cLBP, with a goal to also explore the relevant neuroanatomy. We extracted brain gray matter (GM) density from magnetic resonance imaging scans of 47 patients with cLBP and 47 healthy controls. cLBP was classified with an accuracy of 76% by support vector machine analysis. Primary drivers of the classification included areas of the somatosensory, motor, and prefrontal cortices--all areas implicated in the pain experience. Differences in areas of the temporal lobe, including bordering the amygdala, medial orbital gyrus, cerebellum, and visual cortex, were also useful for the classification. Our findings suggest that cLBP is characterized by a pattern of GM changes that can have discriminative power and reflect relevant pathological brain morphology.

Objectives: (1) To attain a quantitative estimate of patient satisfaction with physiotherapy care for musculoskeletal conditions in Australia; (2) to compare the observed level of patient satisfaction with care in Australia with those from other countries; and (3) to compare factors contributing to patient satisfaction between Australia and the United States (US). Methods: We conducted a prospective study of 274 patients presenting for physiotherapy treatment of a musculoskeletal disorder in Australian clinics. Patient satisfaction was measured using the 20-item MedRisk Instrument for Measuring Patient Satisfaction with Physical Therapy Care (MRPS) and satisfaction scores were compared with those from Northern Europe, North America, the United Kingdom, and Ireland. To investigate factors contributing to patient satisfaction between Australia and the US, we compared 20item MRPS data from Australian and Spanish-speaking US cohorts. Results: Mean Australian MRPS satisfaction score was 4.55 (95% confidence interval: 4.51–4.59) on a scale of 1 to 5, where 1 indicates high dissatisfaction and 5 indicates high satisfaction. This high level of patient satisfaction is consistent with international data. Australian respondents specifically valued interpersonal aspects of care, including advice and information about their condition and an explanation about selfmanagement. The correlation between treatment outcomes and global patient satisfaction was low (r520.22). A comparison of data collected from Australia and the US showed that MRPS items regarding interpersonal aspects of care, such as the therapists’ communication skills, correlated strongly with global satisfaction in both countries. However, there were other questionnaire items for which the correlation with global satisfaction was significantly different between Australia and the US. Conclusions: Patient satisfaction with musculoskeletal physiotherapy care in Australia is high and comparable with Northern Europe, North America, the United Kingdom and Ireland. Comparison of data between Australia and the US indicates that while some determinants of patient satisfaction are common, country-specific differences also exist.

The aim of this study was to test the capacity of the Fear Avoidance Model to explain the relationship between pain and disability in patients with whiplash-associated disorders. Using the method of Baron and Kenny [1], we assessed the mediating effect of fear of movement on the cross-sectional and longitudinal relationships between pain and disability. Two hundred and five subjects with neck pain due to a motor vehicle accident provided pain intensity (0 to 10 numerical rating scale), fear of movement (Tampa Scale of Kinesiophobia and Pictorial Fear of Activity Scale) and disability (Neck Disability Index) scores within 4 weeks of their accident, after 3 months, and after 6 months. The analyses were consistent with the Fear Avoidance Model mediating approximately 20% to 40% of the relationship between pain and disability. Contrary to our initial hypothesis, the proportion of the total effect of pain on disability that was mediated by fear of movement did not substantially change as increasing time elapsed after the accident. The proportion mediated was slightly higher when fear of movement was measured by Tampa Scale of Kinesiophobia as compared with Pictorial Fear of Activity Scale. The findings of this study suggest that the Fear Avoidance Model plays a role in explaining a moderate proportion of the relationship between pain and disability after whiplash injury. © 2011 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Low back pain (LBP) is a common, complex and difficult to manage health condition [1]. Approximately, 20% of the adult population experience an episode of LBP at any given time and estimates of lifetime prevalence are around 80% [2]. Despite intensive research, management is only moderately effective [3]. The economic burden of LBP is significant. For example, in the USA health-care expenditure for LBP is more than $90 billion/year [4], in the UK it is $17 billion/year [5] and in Australia $1 billion/year [6]. Most of the costs of LBP are associated with persistent or chronic LBP, i.e. LBP which lasts for more than 3 months [6]. There are several important consequences of LBP including work loss [7], disability and depression [8]. Considerable attention has been applied to understanding and managing these problems [9], often with limited success. Evidence is beginning to accumulate that patients with LBP also report significant problems with their sleep [10, 11]. Poor sleep is known to cause a range of physiological and psychological effects [12]. Over the long term, these effects can become severe and lead to serious health conditions such as depression, obesity, type-2 diabetes, hypertension and coronary artery disease [13, 14]. From a clinical perspective, the presence of sleep problems has implications for the management of LBP. For example, a recent study found that LBP patients who reported sleep disturbance were twice as likely to be hospitalised compared with those who did not [15]. Other research suggests that improved sleep quality might reduce pain and daytime symptoms of patients with arthritis [16]. It is currently unclear how common sleep disturbance is for patients who are seeking care for their LBP, as estimates have been based on either highly selected groups of patients, such as the elderly or those attending specialist pain clinics [17–19], or small samples of chronic LBP patients [7, 20, 21]. These studies are likely to provide prevalence estimates that may not generalise to more heterogeneous samples of patients who are seeking care for their LBP. High quality data on the prevalence of sleep disturbance in this group of patients will determine whether research resources should be directed towards understanding the relationship between these conditions. Differences in prevalence rates between patients with acute or persistent pain may help identify a patient group that is at risk of developing chronic sleep problems. Finally, investigating the relationship between pain intensity and sleep disturbance may provide directions for the design of interventions to manage these conditions. The aim of this study was to investigate sleep disturbance in a large heterogeneous sample of patients seeking care for their LBP. Specifically, we aimed to determine: the prevalence of reported sleep disturbance in people with LBP; whether sleep disturbance in patients seeking care for their LBP was associated with the duration of their LBP symptoms or with pain intensity.

OBJECTIVES: Increased sensitivity to pressure is commonly associated with painful musculoskeletal conditions, including whiplash-associated disorders (WADs). Pressure pain thresholds (PPTs) close to the site of presumed tissue damage are thought to represent the degree of peripheral nociceptive sensitization. PPTs over healthy tissue, away from the site of injury, are a marker of central nervous system hyperexcitability. There is uncertainty, however, as to what extent does the sensitization of the nociceptive system, whether peripheral or central, contribute to the ongoing, habitual pain experienced by people with WAD. METHODS: One hundred patients with WAD were assessed within 4 weeks of their accident and followed after 3 months; 24-hour average neck pain score, PPTs at the cervical spine and tibialis anterior, demographic factors, and psychological measures were collected. RESULTS: Cervical PPT and neck pain score were significantly, but weakly correlated (r=-0.20 to -0.33). There was no significant correlation between tibialis anterior PPT and pain score at any time point (r=-0.01 to -0.21). Regression analyses indicated a strong influence of generalized psychological distress and fear avoidance on the relationship between PPT and pain report. DISCUSSION: The competing explanations for these findings are that either PPTs provide a poor marker of peripheral and central sensitivity or that these processes are only weakly related to the day-to-day pain experienced by patients with WAD. The latter explanation is supported by the confounding effect of psychological factors on pain score. Language: en