Search

Background: Subjective pain intensity can be measured using instruments like the Faces Pain Scale-Revised (FPS-R), Verbal Rating Scale (VRS), Numerical Pain Rating Scale (NPRS), and Visual Analogue Scale (VAS). However, information on physiotherapists' and patients' knowledge and preference for these tools is scarce., Objective: We investigated the knowledge and preference of physiotherapists and participants with musculoskeletal pain (MP) regarding the pain intensity measurement scales., Methods: This cross-sectional study consisted of physiotherapists and participants with MP. Physiotherapists were recruited via social media for an online open survey, gathering sociodemographic, professional data, and their knowledge and preferences for pain intensity scales. Participants over 18 with MP, participated in interviews focusing on their familiarity and preferences for pain intensity scales. Data was analyzed descriptively, and Chi-squared test evaluated scale preferences., Results: We included 352 physiotherapists (mean experience = 10.5 years) and 94 participants with MP. Of the physiotherapists, 94.3% were familiar with pain scales, but 30.4% struggled to differentiate them. The NPRS was the most used (56.3%) and preferred scale (52.4%). Among participants with MP, unfamiliarity was noted with all scales. After instruction, 46% preferred FPS-R, with preference varying by income and education levels (p < 0.001)., Conclusion: We found a knowledge gap among physiotherapists in identifying pain intensity scales, with a preference for the NPRS among those familiar with the scales. Participants with MP had limited familiarity with these scales. After instructions, these participants preferred the FPS-R, particularly those with lower income and education levels., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objectives: The aim of this study was to assess the accuracy and readability of the answers generated by large language model (LLM)-chatbots to common patient questions about low back pain (LBP)., Methods: This cross-sectional study analysed responses to 30 LBP-related questions, covering self-management, risk factors and treatment. The questions were developed by experienced clinicians and researchers and were piloted with a group of consumer representatives with lived experience of LBP. The inquiries were inputted in prompt form into ChatGPT 3.5, Bing, Bard (Gemini) and ChatGPT 4.0. Responses were evaluated in relation to their accuracy, readability and presence of disclaimers about health advice. The accuracy was assessed by comparing the recommendations generated with the main guidelines for LBP. The responses were analysed by two independent reviewers and classified as accurate, inaccurate or unclear. Readability was measured with the Flesch Reading Ease Score (FRES)., Results: Out of 120 responses yielding 1069 recommendations, 55.8% were accurate, 42.1% inaccurate and 1.9% unclear. Treatment and self-management domains showed the highest accuracy while risk factors had the most inaccuracies. Overall, LLM-chatbots provided answers that were 'reasonably difficult' to read, with a mean (SD) FRES score of 50.94 (3.06). Disclaimer about health advice was present around 70%-100% of the responses produced., Conclusions: The use of LLM-chatbots as tools for patient education and counselling in LBP shows promising but variable results. These chatbots generally provide moderately accurate recommendations. However, the accuracy may vary depending on the topic of each question. The reliability level of the answers was inadequate, potentially affecting the patient's ability to comprehend the information., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ on behalf of EULAR.)

Background: Pain is prevalent among children and adolescents. The development and implementation of Pain Neuroscience Education (PNE) strategies tailored to this population remains overlooked in contrast to the adult population., Objective: This study sought to identify the content, delivery methods, and dosage of PNE for children and adolescents available in the literature., Method: We systematically searched PubMed, EMBASE, Physiotherapy Evidence Database, Scopus, Web of Science, Cochrane Library, PsycINFO, and clinical trial registration databases. Inclusion criteria consisted of studies that involved children submitted to a PNE program in community, school, clinics, hospitals or child development centers. We considered studies that included children with and without pain who received PNE strategies associated or not with self-motivational interventions. Studies focusing on psychological interventions were excluded. We extracted data on authors, publication year, country, sample characteristics, health condition, PNE content, study design, context, outcomes, duration, follow-up, main results, dropout, and adverse effects. Data extracted were qualitatively organized., Results: A total of 805 studies were initially reviewed. The final sample comprised 17 studies. Common PNE topics included pain neurophysiology, biopsychosocial influences, pain concepts, self-management, and coping strategies. Delivery methods ranged from slideshows and videos to booklets, with sessions lasting 8-60 min. Schools were the most common setting for these interventions., Conclusion: Our review demonstrates the diversity in PNE content, delivery methods, and intervention dosages among the included studies. Most studies occurred in school settings, potentially limiting its generalizability for clinical contexts., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Machine learning (ML) efficiently processes large datasets, showing promise in enhancing clinical practice within physical therapy., Objective: The aim of this scoping review is to provide an overview of studies using ML approaches in clinical settings of physical therapy., Data Sources: A scoping review was performed in PubMed, EMBASE, PEDro, Cochrane, Web of Science, and Scopus., Selection Criteria: We included studies utilizing ML methods. ML was defined as the utilization of computational systems to encode patterns and relationships, enabling predictions or classifications with minimal human interference., Data Extraction and Data Synthesis: Data were extracted regarding methods, data types, performance metrics, and model availability., Results: Forty-two studies were included. The majority were published after 2020 (n = 25). Fourteen studies (33.3%) were in the musculoskeletal physical therapy field, nine (21.4%) in neurological, and eight (19%) in sports physical therapy. We identified 44 different ML models, with random forest being the most used. Three studies reported on model availability. We identified several clinical applications for ML-based tools, including diagnosis (n = 14), prognosis (n = 7), treatment outcomes prediction (n = 7), clinical decision support (n = 5), movement analysis (n = 4), patient monitoring (n = 3), and personalized care plan (n = 2)., Limitation: Model performance metrics, costs, model interpretability, and explainability were not reported., Conclusion: This scope review mapped the emerging landscape of machine learning applications in physical therapy. Despite the growing interest, the field still lacks high-quality studies on validation, model availability, and acceptability to advance from research to clinical practice., Competing Interests: Declaration of competing interest None of the authors has any conflicts of interest to declare., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Abstract: Recent studies highlight an interplay between pain perception and emotional responses. This necessitates a thorough investigation into how beliefs and motivational influences respond to visual stimuli of movements. Such an analysis is crucial for understanding the extent to which these factors contribute to disability levels associated with shoulder pain. We aimed to investigate the relationship between the perception of harm and the valence in images depicting shoulder movements and determine how these perceptions are linked to disability levels associated with shoulder pain. This cross-sectional study recruited 42 individuals with chronic shoulder pain. Participants were presented with 58 shoulder movements images. Each participant evaluated these images for emotional valence and arousal using the self-assessment manikin. For every image, they provided their level of avoidance, fear, and perception of harm in a numerical scale. We measured disability levels and pain catastrophizing using the Shoulder Pain and Disability Index and the Pain Catastrophizing Scale. A direct acyclic graph was used. Multiple linear regression analysis was conducted with shoulder disability as the dependent variable and perception of harm and valence as independent variables, adjusted for the confounders catastrophizing and arousal. This analysis resulted in a significant model (F4,37 = 11.44; adjusted R2 = 0.547; P < 0.01). The perception of harm to shoulder movement (β = 0.11; P < 0.001; 95% confidence interval = 5.6-11.8) was significantly associated with the level of shoulder disability, whereas valence did not show a significant association (β = 0.26; P = 0.15; 95% confidence interval = 1.7-10.8). The perception of harm associated with shoulder movements images during daily activities was associated with disability. Individuals who believe that shoulder movements are harmful have greater disability., (Copyright © 2024 International Association for the Study of Pain.)

Introduction and Hypothesis: The Choosing Wisely campaign is an international initiative that is aimed at promoting a dialog between professionals, helping the population to choose an evidence-based, truly necessary and risk-free care. The aim of the study was to develop the Choosing Wisely Brazil list on Women's Health Physiotherapy in the area of the pelvic floor., Methods: A observational study was carried out between January 2022 and July 2023, proposed by the Brazilian Association of Physiotherapy in Women's Health, and developed by researchers working in the area of the pelvic floor. The development of the list consisted of six stages: a panel of experts, consensus building, national research, a review by the Choosing Wisely Brazil team, preparation of the list, and publication of the recommendations. Descriptive and content analyses were carried out in order to include evidence-based recommendations with over 80% agreement by physiotherapists in Brazil., Results: The expert panel was made up of 25 physiotherapists who submitted 63 recommendations. Seven physiotherapists/researchers carried out a critical analysis of the literature and refined the recommendations, resulting in 11 recommendations that were put to a national vote, in which 222 physiotherapists took part. After a review by the Choosing Wisely Brazil team, five recommendations with an average agreement of 88.2% agreement were chosen for publication., Conclusions: The Choosing Wisely Brazil team in Physiotherapy in Women's Health/Pelvic Floor proposed a list of five recommendations that showed a high agreement among Brazilian physiotherapists working in the area., (© 2024. The International Urogynecological Association.)

Background: The development and application of Artificial Intelligence (AI) and Machine Learning (ML) in healthcare have gained attention as a promising and powerful resource to change the landscape of healthcare. The potential of these technologies for injury prediction, performance analysis, personalized training, and treatment comes with challenges related to the complexity of sports dynamics and the multidimensional aspects of athletic performance., Objectives: We aimed to present the current state of AI and ML applications in sports science, specifically in the areas of injury prediction, performance enhancement, and rehabilitation. We also examine the challenges of incorporating AI and ML into sports and suggest directions for future research., Method: We conducted a comprehensive literature review, focusing on publications related to AI and ML applications in sports. This review encompassed studies on injury prediction, performance analysis, and personalized training, emphasizing the AI and ML models applied in sports., Results: The findings highlight significant advancements in injury prediction accuracy, performance analysis precision, and the customization of training programs through AI and ML. However, future studies need to address challenges such as ethical considerations, data quality, interpretability of ML models, and the integration of complex data., Conclusion: AI and ML may be useful for the prevention, detection, diagnosis, and treatment of health conditions. In this Masterclass paper, we introduce AI and ML concepts, outline recent breakthroughs in AI technologies and their applications, identify the challenges for further progress of AI systems, and discuss ethical issues, clinical and research opportunities, and future perspectives., Competing Interests: Declaration of competing interest The authors declare no competing interest., (Copyright © 2024 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Computational linguistics allows an understanding of language structure and different forms of expression of patients' perceptions., Aims: The aims of this study were (i) to carry out a descriptive analysis of the discourse of people with chronic low back pain using sentiment analysis (SA) and network analysis; (ii) to verify the correlation between patients' profiles, pain intensity and disability levels with SA and network analysis; and (iii) to identify clusters in our sample according to language and SA using an unsupervised machine learning technique., Methods: We performed a secondary analysis of a qualitative study including participants with chronic non-specific low back pain. We used the data related to participants' feelings when they received the diagnosis. The SA and network analysis were performed using the Valence Aware Dictionary and sEntiment Reasoner, and the Speech Graph, respectively. Clustering was performed using the K-means algorithm., Results: In the SA, the mean composite score was -0.31 (Sd. = 0.58). Most participants presented a negative discourse (n = 41; 72%). Word Count (WC) and Largest Strongly connected Component (LSC) positively correlated with education. No statistically significant correlations were observed between pain intensity, disability levels, SA, and network analysis. Two clusters were identified in our sample., Conclusion: The SA showed that participants reported their feeling when describing the moment of the diagnosis using sentences with negative discourse. We did not find a statistically significant correlation between pain intensity, disability levels, SA, and network analysis. Education level presented positive correlation with WC and LSC., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objectives: Hench introduced the fibromyalgia syndrome almost 50 years ago. In the meantime, the prevalence has increased, the clinical criteria have changed and the way we explain (chronic) pain has altered., Design: In the current study, we conducted a worldwide survey in which we investigate whether medical doctors are familiar with the American College of Rheumatology (ACR) criteria for fibromyalgia and, if so, whether these medical doctors adhere to the clinical guidelines following evidence-based treatments., Results: In total, 286 medical doctors from 43 countries spread over 6 continents filled out the survey. In most of the countries, the diagnosis fibromyalgia was used. Only 10% adhere to the ACR criteria, widespread pain (44%), unrefreshed sleep (24%), fatigue (20%) and cognitive problems (8%) were most used diagnostic criteria. Of the respondents, 94 (32%) mentioned that the cause is unknown or idiopathic, but also a wide variety of other causes was mentioned. More than 70 different treatment options were provided, of which 24% of the responses were classified as according to the clinical guidelines. From this study, we conclude that many medical doctors do not follow the ACR criteria; the majority has an inappropriate knowledge of causes for fibromyalgia and that a minority of treatment advice adhere to the guidelines., (© 2023 World Institute of Pain.)

The potential to classify low back pain as being characterised by dominant nociceptive, neuropathic, or nociplastic mechanisms is a clinically relevant issue. Preliminary evidence suggests that these low back pain phenotypes might respond differently to treatments; however, more research must be done before making specific recommendations. Accordingly, the low back pain phenotyping (BACPAP) consortium was established as a group of 36 clinicians and researchers from 13 countries (five continents) and 29 institutions, to apply a modified Nominal Group Technique methodology to develop international and multidisciplinary consensus recommendations to provide guidance for identifying the dominant pain phenotype in patients with low back pain, and potentially adapt pain management strategies. The BACPAP consortium's recommendations are also intended to provide direction for future clinical research by building on the established clinical criteria for neuropathic and nociplastic pain. The BACPAP consortium's consensus recommendations are a necessary early step in the process to determine if personalised pain medicine based on pain phenotypes is feasible for low back pain management. Therefore, these recommendations are not ready to be implemented in clinical practice until additional evidence is generated that is specific to these low back pain phenotypes., Competing Interests: Declaration of interests BM received consultation fees from Haleon, GSK, and Grünenthal, and honoraria from Haleon, GSK, Grünenthal, Krka, Mundipharma, and Viatris, is the past president of the European Pain Federation and program director of the Belgian Interuniversity Course in Pain Management. AC received payment for work as group tutor for the course in Clinimetrics (EpidM, Amsterdam, Netherlands). JN and the Vrije Universiteit Brussel received lecturing or teaching fees from various professional associations and educational organisations. EKo received royalties for textbook chapters from Liber and Studentlitteratur, payment for a lecture from Eli Lilly, and is a member of the scientific board of the Swedish Rheumatism Association. PH received travel support from the German Osteopathic Society, the Icelandic Physiotherapy Association, and the Finish Musculoskeletal Medicine Society. All other authors declared no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Pain is a major public health concern associated with emotional disorders and physical disability and generates increased sick leave and healthcare expenditures. However, despite its social impact and the high pain-related costs, the training of healthcare professionals, such as physical therapists, in pain management is insufficient, leading to an inadequate therapeutic approach. This study aimed to determine the existence of a specific program on pain within the curricula of physical therapy careers in accredited universities in Chile. Out of 40 physical therapy careers, we analyzed 38 curricula. None of them had a specific discipline on pain management in their curricula. Although there is no concrete definition of the best modality for pain education in undergraduate students, it has been shown that following the International Association for The Study of Pain curricula improves students' knowledge and awareness of pain management., Competing Interests: This work is licensed under a Creative Commons Attribution 4.0 International License.

Objective: The Avoidance of Daily Activities Photo Scale for Patients With Shoulder Pain (ADAP Shoulder Scale) was developed to assess pain-related avoidance behavior during daily activities in people with shoulder pain. However, its measurement properties must be verified according to international guidelines. As such, this study investigated the following 4 measurement properties of the ADAP Shoulder Scale: reliability, measurement errors, convergent validity, and floor and ceiling effects., Methods: The sample comprised 100 individuals with chronic shoulder pain (43 men and 57 women; mean duration of symptoms of 29.7 [SD = 89.0] months; mean age of 44.9 [SD = 15.9] years). The mean test-retest reliability range was 5 days via the intraclass correlation coefficient (ICC). Measurement errors included the standard error of measurement and the minimal detectable change. Convergent validity was analyzed by applying the Pearson correlation with the Tampa Scale for Kinesiophobia, Pain Catastrophizing Scale, and Shoulder Pain and Disability Index., Results: The ADAP Shoulder Scale showed excellent test-retest reliability, both in all domains and in the total score [ICC(2,1) = 0.94; 95% CI = 0.92-0.96]. The standard errors of measurement for the free-movement, high-effort, and self-care domains were 8.1%, 6.0%, and 7.6%, respectively. The minimal detectable change for the total score of the ADAP Shoulder Scale was 16.0%. The total score of the ADAP Shoulder Scale was low to moderately correlated with the total scores of the Tampa Scale for Kinesiophobia (r = 0.52), Pain Catastrophizing Scale (r = 0.30), and Shoulder Pain and Disability Index (r = 0.72). No floor or ceiling effects were detected in the total score., Conclusion: The ADAP Shoulder Scale is a reliable, valid instrument for assessing avoidance behavior in adults who have chronic shoulder pain and are not athletes., Impact: This study provides evidence that the ADAP Shoulder Scale is appropriate for clinical and practical use in people with chronic shoulder pain., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: The rise in opioid prescriptions with a parallel increase in opioid use disorders remains a significant challenge in some developed countries (opioid epidemic). However, little is known about opioid consumption in low- and middle-income countries (LMICs). In this short report, we aim to discuss the increase in opioid consumption in LMICs by providing an update on the opioid perspective in Brazil., Methods: We analyzed opioid sales on the publicly available Brazilian Health Regulatory Agency (ANVISA) database from 2015 to 2020., Results: In Brazil, opioid sales increased 34.8 %, from 8,839,029 prescriptions in 2015 to 11,913,823 prescriptions in 2020, this represents an increase from 44 to 56 prescriptions for every 1,000 inhabitants. Codeine phosphate combined with paracetamol and tramadol hydrochloride were the most common opioids prescribed with an increase each year., Conclusions: The results suggest that opioid prescriptions are rising in Brazil in a 5 years period. Brazil may have a unique opportunity to learn from other countries and develop consistent policies and guidelines to better educate patients and prescribers and to prevent an opioid crisis., (© 2023 the author(s), published by De Gruyter, Berlin/Boston.)

Actions towards the health-related Sustainable Development Goal 3.4 typically focus on non-communicable diseases (NCDs) associated with premature mortality, with less emphasis on NCDs associated with disability, such as musculoskeletal conditions-the leading contributor to the global burden of disability. Can systems strengthening priorities for an underprioritised NCD be codesigned, disseminated and evaluated? A 'roadmap' for strengthening global health systems for improved musculoskeletal health was launched in 2021. In this practice paper, we outline dissemination efforts for this Roadmap and insights on evaluating its reach, user experience and early adoption. A global network of 22 dissemination partners was established to drive dissemination efforts, focussing on Africa, Asia and Latin America, each supported with a suite of dissemination assets. Within a 6-month evaluation window, 52 Twitter posts were distributed, 2195 visitors from 109 countries accessed the online multilingual Roadmap and 138 downloads of the Roadmap per month were recorded. Among 254 end users who answered a user-experience survey, respondents 'agreed' or 'strongly agreed' the Roadmap was valuable (88.3%), credible (91.2%), useful (90.1%) and usable (85.4%). Most (77.8%) agreed or strongly agreed they would adopt the Roadmap in some way. Collection of real-world adoption case studies allowed unique insights into adoption practices in different contexts, settings and health system levels. Diversity in adoption examples suggests that the Roadmap has value and adoption potential at multiple touchpoints within health systems globally. With resourcing, harnessing an engaged global community and establishing a global network of partners, a systems strengthening tool can be cocreated, disseminated and formatively evaluated., Competing Interests: Competing interests: AMB reports grant income from AO Alliance, Asia Pacific League of Associations for Rheumatology, Australian Rheumatology Association, Curtin University, Pan American League of Associations for Rheumatology, and World Federation of Chiropractic related to the current work. AMB reports grant funding from the Australian Government, Department of Health; Medical Research Future Fund (Australian National Health and Medical Research Council); Western Australian Government Department of Health; Bone and Joint Decade Foundation; Curtin University; Institute for Bone and Joint Research (Australia); Canadian Memorial Chiropractic College; and Arthritis and Osteoporosis Western Australia outside the submitted work. AMB reports consultancy fees and travel support from the WHO and speaker fees from the American College of Rheumatology outside the current work. JC: reports personal income from Curtin University related to the current work. MC: reports institutional income from the Bone and Joint Decade Foundation related to the current work; and Royalties from Up-to-Date unrelated the current work. NMA: nothing to disclose. LF: reports leadership roles with World Physiotherapy and the International Federation of orthopaedic Manipulative Physical Therapists. SAH: nothing to disclose. MJ: reports a leadership role with AO Alliance and personal fees. AAK: nothing to disclose. LM: reports institutional income from the Bone and Joint Decade Foundation related to the current work. LM reports grant income from Janssen Australia, NHMRC Australian Government CREE for Inflammatory Arthritis, MRFF Australian Government Adult Arthritis Biologic Tapering Trial, and MRFF Australian Government Juvenile Arthritis Biologic Tapering Trial outside the current work. LM reports data safety monitoring (unpaid) on an Australian Government funded trial for opioid medicines. LM reports leadership positions with the Global Alliance for Musculoskeletal Health and the Australian Rheumatology Association. FM: reports a leadership position with the International Federation of Musculoskeletal Research Societies. FR: nothing to disclose. SSarfraz: nothing to disclose. SSharma: reports fellowship funding from the International Association for the Study of Pain (IASP) and speaker fees and travel support from the IASP unrelated to the current work. SSharma reports leadership positions with the IASP. ERS: reports income from PANLAR, Abbvie, Elea and Pfizer outside the current work; testimony fees from Abbvie, Amgen, BMS, Glaxo, Janssen, Lilly, Novartis, Pfizer, Sandoz, UCB; and support for attening meetings from Abbvie, Janssen, Pfizer, UCB, Amgen. HS: reports grant income from AO Alliance, Asia Pacific League of Associations for Rheumatology, Australian Rheumatology Association, Curtin University, Pan American League of Associations for Rheumatology, and World Federation of Chiropractic related to the current work. HS reports grant funding from the Australian Government, Department of Health; Medical Research Future Fund (Australian National Health and Medical Research Council); Western Australian Government Department of Health; Bone and Joint Decade Foundation; Curtin University; Institute for Bone and Joint Research (Australia); and Canadian Memorial Chiropractic College outside the submitted work. HS reports travel support from the Australian Pain Society to attend a scientific meeting., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The identification of factors that influence the efficacy of endogenous pain inhibitory pathways remains challenging due to different protocols and populations. We explored five machine learning (ML) models to estimate the Conditioned Pain Modulation (CPM) efficacy., Design: Exploratory, cross-sectional design., Setting and Participants: This study was conducted in an outpatient setting and included 311 patients with musculoskeletal pain., Methods: Data collection included sociodemographic, lifestyle, and clinical characteristics. CPM efficacy was calculated by comparing the pressure pain thresholds before and after patients submerged their non-dominant hand in a bucket of cold water (cold-pressure test) (1-4 °C). We developed five ML models: decision tree, random forest, gradient-boosted trees, logistic regression, and support vector machine., Main Outcome Measures: Model performance were assessed using receiver operating characteristic curve (AUC), accuracy, sensitivity, specificity, precision, recall, F1-score, and the Matthews Correlation Coefficient (MCC). To interpret and explain the predictions, we used SHapley Additive explanation values and Local Interpretable Model-Agnostic Explanations., Results: The XGBoost model presented the highest performance with an accuracy of 0.81 (95% CI = 0.73 to 0.89), F1 score of 0.80 (95% CI = 0.74 to 0.87), AUC of 0.81 (95% CI: 0.74 to 0.88), MCC of 0.61, and Kappa of 0.61. The model was influenced by duration of pain, fatigue, physical activity, and the number of painful areas., Conclusions: XGBoost showed potential in predicting the CPM efficacy in patients with musculoskeletal pain on our dataset. Further research is needed to ensure the external validity and clinical utility of this model., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Although clinical practice guidelines recommend pain education as the first-line option for the management of chronic musculoskeletal pain, there is a lack of pain education programmes in healthcare. Thus, digital health programmes can be an effective tool for implementing pain education strategies for public health. This trial will aim to analyse the implementation and effectiveness outcomes of three online pain science education strategies in the Brazilian public health system (SUS) for individuals with chronic musculoskeletal pain., Methods: We will conduct a hybrid type III effectiveness-implementation randomised controlled trial with economic evaluation. We will include adult individuals with chronic musculoskeletal pain, recruited from primary healthcare in the city of Guarapuava, Brazil. Individuals will be randomised to three implementation groups receiving a pain science education intervention (EducaDor) but delivered in different modalities: group 1) synchronous online; group 2) asynchronous videos; and group 3) interactive e-book only. Implementation outcomes will include acceptability, appropriateness, feasibility, adoption, fidelity, penetration, sustainability, and costs. We will also assess effectiveness outcomes, such as pain, function, quality of life, sleep, self-efficacy, and adverse effects. Cost-effectiveness and cost-utility analyses will be conducted from the SUS and societal perspectives. The evaluations will be done at baseline, post-intervention (10 weeks), and 6 months., Discussion: This study will develop and implement a collaborative intervention model involving primary healthcare professionals, secondary-level healthcare providers, and patients to enhance self-management of chronic pain. In addition to promoting better pain management, this study will also contribute to the field of implementation science in public health by generating important insights and recommendations for future interventions., Trial Registration: ClinicalTrials.gov (NCT05302180; 03/29/2022)., (© 2023. The Author(s).)

Musculoskeletal (MSK) health impairments contribute substantially to the pain and disability burden in low- and middle-income countries (LMICs), yet health systems strengthening (HSS) responses are nascent in these settings. We aimed to explore the contemporary context, framed as challenges and opportunities, for improving population-level prevention and management of MSK health in LMICs using secondary qualitative data from a previous study exploring HSS priorities for MSK health globally and (2) to contextualize these findings through a primary analysis of health policies for integrated management of non-communicable diseases (NCDs) in select LMICs. Part 1: 12 transcripts of interviews with LMIC-based key informants (KIs) were inductively analysed. Part 2: systematic content analysis of health policies for integrated care of NCDs where KIs were resident (Argentina, Bangladesh, Brazil, Ethiopia, India, Kenya, Malaysia, Philippines and South Africa). A thematic framework of LMIC-relevant challenges and opportunities was empirically derived and organized around five meta-themes: (1) MSK health is a low priority; (2) social determinants adversely affect MSK health; (3) healthcare system issues de-prioritize MSK health; (4) economic constraints restrict system capacity to direct and mobilize resources to MSK health; and (5) build research capacity. Twelve policy documents were included, describing explicit foci on cardiovascular disease (100%), diabetes (100%), respiratory conditions (100%) and cancer (89%); none explicitly focused on MSK health. Policy strategies were coded into three categories: (1) general principles for people-centred NCD care, (2) service delivery and (3) system strengthening. Four policies described strategies to address MSK health in some way, mostly related to injury care. Priorities and opportunities for HSS for MSK health identified by KIs aligned with broader strategies targeting NCDs identified in the policies. MSK health is not currently prioritized in NCD health policies among selected LMICs. However, opportunities to address the MSK-attributed disability burden exist through integrating MSK-specific HSS initiatives with initiatives targeting NCDs generally and injury and trauma care., (© The Author(s) 2022. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Abstract: Cognitive functional therapy (CFT) is a physiotherapy-led intervention that has evolved from an integration of foundational behavioral psychology and neuroscience within the physiotherapist practice directed at the multidimensional nature of chronic low back pain (CLBP). The current evidence about the comparative effectiveness of CFT for CLBP is still scarce. We aimed to investigate whether CFT is more effective than core training exercise and manual therapy (CORE-MT) in pain and disability in patients with CLBP. A total of 148 adults with CLBP were randomly assigned to receive 5 one-hour individualized sessions of either CFT (n = 74) or CORE-MT (n = 74) within a period of 8 weeks. Primary outcomes were pain intensity (numeric pain rating scale, 0-10) and disability (Oswestry Disability Index, 0-100) at 8 weeks. Patients were assessed preintervention, at 8 weeks and 6 and 12 months after the first treatment session. Altogether, 97.3% (n = 72) of patients in each intervention group completed the 8 weeks of the trial. Cognitive functional therapy was more effective than CORE-MT in disability at 8 weeks (MD = -4.75; 95% CI -8.38 to -1.11; P = 0.011, effect size= 0.55) but not in pain intensity (MD = -0.04; 95% CI -0.79 to 0.71; P = 0.916). Treatment with CFT reduced disability, but the difference was not clinically important compared with CORE-MT postintervention (short term) in patients with CLBP. There was no difference in pain intensity between interventions, and the treatment effect was not maintained in the mid-term and long-term follow-ups., (Copyright © 2022 International Association for the Study of Pain.)

Pain affects everyone hence one can argue that it is in each individual's interest to understand pain in order to hold correct and adaptive beliefs and attitudes about pain. In addition, chronic pain is reaching pandemic proportions and it is now well known that people living with chronic pain have a reduced life expectancy. To address and to prevent the growth of this public health disaster, we must start looking beyond adulthood. How children view pain has an impact on their behavioral coping responses which in turn predict persistent pain early in the lifespan. In addition, children who suffer from chronic pain and who are not (properly) treated for it before adolescence have an increased risk of having chronic pain during their adult life. Explaining pain to children and youth may have a tremendous impact not only on the individual child suffering from chronic pain but also on society, since the key to stop the pain pandemic may well lie in the first two decades of life. In order to facilitate the acquisition of adaptive behavioral coping responses, pain education aims to shift people's view on pain from being an apparent threat towards being a compelling perceptual experience generated by the brain that will only arise whenever the conceivable proof of danger to the body is greater than the conceivable proof of safety to the body. Nowadays a lot of pain education material is available for adults, but it is not adapted to children's developmental stage and therefore little or not suitable for them. An overview of the state-of-the-art pain education material for children and youth is provided here, along with its current and future areas of application as well as challenges to its development and delivery. Research on pediatric pain education is still in its infancy and many questions remain to be answered within this emerging field of investigation., (© 2022. The Author(s).)

Background: The aims of this study were twofold: (1) to compare the body image and tactile acuity of patients with fibromyalgia and asymptomatic participants, and (2) to investigate the effects of an 8-week exercise-based intervention (aerobic or Pilates exercises) on the body image, tactile acuity, and pain intensity in patients with fibromyalgia., Methods: A cross-sectional study and a secondary analysis of a randomized controlled trial were carried out, which assessed the following outcomes in 24 patients with fibromyalgia and 24 asymptomatic participants: subjective body image (Drawing Test), tactile acuity (Two-Point Discrimination Test), limb circumference (Cirtometry), and pain (Pain Numerical Rating Scale). After the assessment, the 24 patients with fibromyalgia were randomly allocated to one of the intervention groups: aerobic or Pilates., Results: There was no significant difference in the tactile acuity of the cervical, lumbar, hands, and feet regions between the participants with fibromyalgia and the asymptomatic participants (p > 0.05). However, patients with fibromyalgia showed changes in subjective body image when the drawings were compared to the cirtometry measurements. After the intervention, there was no significant difference between aerobic exercise and Pilates for pain and tactile acuity in the cervical, lumbar, hands, and feet regions of patients with fibromyalgia (p > 0.05)., Conclusions: Patients with fibromyalgia presented altered perception in subjective body image but not on tactile acuity, when compared to asymptomatic participants. In addition, there was no difference between aerobic exercise and Pilates for pain and tactile acuity in these patients., (© 2022 World Institute of Pain.)

Background: To verify the use of pain drawing to assess multisite pain in with primary dysmenorrhea (PD) and to assess its divergent validity, test-retest reliability, intra- and inter-rater reliability and measurement errors., Methods: Cross-sectional study. Adult women with self-reported PD three months prior to the study. Women answered the Numerical Rating Scale (NRS) and the pain drawing during two consecutive menstruations. The pain drawings were digitalized and assessed for the calculation of total pain area (%). Intra- and inter-rater reliability and the test-retest reliability between the first and the second menstruations were assessed with the intraclass correlation coefficient (ICC). Measurement errors were calculated with the standard error of measurement (SEM), smallest detectable change (SDC) and the Bland-Altman plot. Spearman correlation (rho) was used to check the correlation between the total pain area and pain intensity of the two menstruations., Results: Fifty-six women (24.1 ± 3.1 years old) participated of the study. Their average pain was 6.2 points and they presented pain in the abdomen (100%), low back (78.6%), head (55.4%) and lower limbs (50%). All reliability measures were considered excellent (ICC > 0.75) for the total pain area; test-retest SEM and SDC were 5.7% and 15.7%, respectively. Inter-rater SEM and SDC were 8% and 22.1%, respectively. Correlation between total pain area and pain intensity was moderate in the first (rho = 0.30; p = 0.021) and in the second menstruations (rho = 0.40; p = 0.002)., Conclusion: Women with PD presented multisite pain, which could be assessed with the pain drawing, considered a reliable measurement., (© 2022. The Author(s).)

Abstract: Classification of musculoskeletal pain based on underlying pain mechanisms (nociceptive, neuropathic, and nociplastic pain) is challenging. In the absence of a gold standard, verification of features that could aid in discrimination between these mechanisms in clinical practice and research depends on expert consensus. This Delphi expert consensus study aimed to: (1) identify features and assessment findings that are unique to a pain mechanism category or shared between no more than 2 categories and (2) develop a ranked list of candidate features that could potentially discriminate between pain mechanisms. A group of international experts were recruited based on their expertise in the field of pain. The Delphi process involved 2 rounds: round 1 assessed expert opinion on features that are unique to a pain mechanism category or shared between 2 (based on a 40% agreement threshold); and round 2 reviewed features that failed to reach consensus, evaluated additional features, and considered wording changes. Forty-nine international experts representing a wide range of disciplines participated. Consensus was reached for 196 of 292 features presented to the panel (clinical examination-134 features, quantitative sensory testing-34, imaging and diagnostic testing-14, and pain-type questionnaires-14). From the 196 features, consensus was reached for 76 features as unique to nociceptive (17), neuropathic (37), or nociplastic (22) pain mechanisms and 120 features as shared between pairs of pain mechanism categories (78 for neuropathic and nociplastic pain). This consensus study generated a list of potential candidate features that are likely to aid in discrimination between types of musculoskeletal pain., (Copyright © 2022 International Association for the Study of Pain.)

Background: Pain experience has a multidimensional nature. Assessment and treatment recommendations for pain conditions suggest clinicians use biopsychosocial approaches to treat pain and disability. The current pain research is overwhelmingly skewed towards the study of biological and psychological factors including interventions, whereas, cultural factors are often ignored., Objective: The aims of this Masterclass is threefold: (1) to discuss cultural influences on pain, (2) to provide strategies for delivering appropriate pain education and exercises in culturally diverse people with chronic pain, and (3) to present challenges and future directions to clinicians and researchers., Discussion: Cultural factors have a relevant influence on the way individuals experience and manage health and illness. Thus, people with different cultural experience perceive, respond, communicate and manage their pain in different ways. In this aspect, the contents of pain education should be presented using different culturally appropriate examples, metaphors, images, and delivery methods that may enhance the impact of the message. Efforts should be made to produce and spread culturally adapted evidence-based materials and resources. In addition, a culturally sensitive approach may help to introduce patients to graded activities, so that they can apply these strategies in culturally acceptable and meaningful ways. Future studies should investigate the effectiveness of culturally-adapted interventions in pain-related outcomes in different pain conditions in patients with different cultural backgrounds., Competing Interests: Conflicts of interest The Vrije Universiteit Brussel (VUB) and Jo Nijs received lecturing fees. Jo Nijs co-authored a Dutch book on pain neuroscience education; the royalties are collected by the VUB., (Copyright © 2022 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objectives: We aimed to adopt a multidimensional approach and investigate the interconnections between biomarkers (cytokines, matrix metalloproteinases, and cortisol) and psychosocial aspects considering pain acceptance, the individual construct of pain perception in terms of blood inflammation biomarkers, anxiety, self-efficacy, and functional performance and to define the quality of life (QoL) in women with rheumatoid arthritis (RA)., Methods: An observational cross-sectional study with a total of 42-RA participants, with chronic pain and 42-women without rheumatic diseases or chronic pain were included. A structural equation model was used to investigate the association between independent variables., Results: Women with RA presented high blood biomarker levels, representing an intense inflammatory process. The participants with RA reported moderate pain most of the time, a worsening QoL, functionality, engagement in activities, and a willingness to live with pain and self-efficacy. It was found that the higher the chronic pain, the greater the intensity of pain perceived by these women with RA, as well as, the worse the functionality, the higher the perceived pain., Conclusions: The exacerbation of pain perception leads to worsening of the experience of chronic pain. The new construct of pain experience should include functionality as a crucial factor in understanding the mechanisms underlying pain., (© Japan College of Rheumatology 2021. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Musculoskeletal pain patients present similar pain characteristics regardless of the clinical diagnosis. PainDETECT questionnaire is useful for screening neuropathic-like symptoms in many musculoskeletal conditions. However, no previous studies compared pain phenotypes of patients with musculoskeletal pain using the painDETECT. Therefore, the current study aimed to compare the pain characteristics of patients with musculoskeletal pain classified according to the painDETECT as nociceptive pain, unclear, and neuropathic-like symptoms., Methods: A cross-sectional study was conducted in 308 participants with musculoskeletal pain. Demographic and clinical characteristics of the participants were examined. Neuropathic-like symptoms, pain intensity, pain area, Central Sensitization-related sign and symptoms, functional limitation, and conditioned pain modulation were assessed in patients with musculoskeletal pain. Independent one-way analysis of variance (ANOVA) was used to test for between-group differences for the outcome measures with continuous variables and Pearson chi-square test verified between-group differences on the efficiency of the conditioned pain modulation., Results: Participants had a mean age of 52.21 (±15.01) years old and 220 (71.42%) were females. One hundred seventy-three (56.16%) participants present nociceptive pain, 69 (22.40%) unclear, and 66 (21.42%) neuropathic-like symptoms. A one-way ANOVA showed differences for the pain intensity [F (2,305) = 20.097; p < .001], pain area [F (2,305) = 28.525; p < .001], Central Sensitization-related sign and symptoms [F (2,305) = 54.186; p < .001], and functional limitation [F (2,256) = 8.061; p < .001]. However, conditioned pain modulation was similarly impaired among the three groups (X 2  = 0.333, p = 0.847)., Conclusion: Patients with neuropathic-like symptoms revealed unfavorable pain characteristics compared to their counterparts, including pain intensity, generalized pain, Central Sensitization-related sign and symptoms, and functional limitation., (© 2022. The Author(s).)

Objectives: The purpose of this study was to develop the Avoidance of Daily Activities Photo Scale (ADAP Shoulder Scale) to measure shoulder pain-related avoidance behavior in patients with shoulder pain and evaluate and report the structural validity and internal consistency of the scale., Methods: Potential daily activities involving the shoulder were selected from the activities and participation domain of the International Classification of Functioning, Disability and Health. The selected activities were presented to an expert panel, health care professionals, and patients with shoulder pain with the question "How much do you think it is important to ask patients with shoulder pain about this activity?" Activities attaining a content validity index (CVI) ≥ 0.8 were represented using a digitally colored photograph. Activity photographs were evaluated by health care professionals and patients with shoulder pain. Photographs with a CVI ≥ 0.8 were included in the scale. To evaluate structural validity and internal consistency of the scale, exploratory factor analysis was performed to determine the presence of any scale domain. Cronbach alpha was calculated to indicate the internal consistency of each domain., Results: Of the 107 preselected activities, 21 attained a CVI ≥ 0.8. Eighteen photographs (CVI ≥ 0.8) were included in the scale after being analyzed by 120 health care professionals and 50 patients with shoulder pain. Exploratory factor analysis (N = 156) showed that the ADAP Shoulder Scale consists of 3 domains: free movement, high effort, and self-care. The internal consistencies of the domains were 0.92, 0.89, and 0.92, respectively., Conclusion: The ADAP Shoulder Scale included 15 photographs distributed in 3 domains. All domains had a high internal consistency. The scale is easily applicable, well understood, and relevant for shoulder pain., Impact: The ADAP Shoulder Scale can be used to rate shoulder pain-related avoidance behaviors., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Websites from official organizations (e.g., Ministry of Health and Professional Councils) are assumed to be trustworthy sources of information., Objective: To investigate the credibility, accuracy, and readability of low back pain (LBP) web-based content in Brazilian official websites., Methods: Mixed-methods review. Google search was used for retrieving web-information about Brazilian trustworthy organizations. We assessed the URLs on three domains: credibility, accuracy, and readability of LBP contents. Qualitative analysis was performed using an open source platform in three stages: (1) organization into thematic units; (2) data exploration; and (3) interpretation of the data and summarization., Results: We included 84 URLs. Accuracy was assessed for 58 URLs and none fully adhered to the guidelines. Credibility analysis was performed for 67 URLs. Disclosure of authorship was not mentioned in 58 (87%) of the URLs, 63 (94%) did not mention the sources of their information, none presented a declaration of conflict of interest, and 16 (24%) did not provide the date of creation. Readability was assessed for 72 URLs and was classified as "easy" to read in 65%. Six main themes emerged in the qualitative analysis: (1) Explanations and causes for LBP, (2) diagnosis, (3) recommendations about medication, (4) recommendations for coping and self-management, (5) performing exercises, and (6) recommendations for children and adolescents., Conclusions: The reading level is appropriate for patient-oriented information. However, Brazilian official websites demonstrated low credibility standards and while some of the content is partially supported by the current literature, there is also much inaccurate information about LBP., Competing Interests: Conflicts of interest The authors declare no conflict of interest., (Copyright © 2022 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: Patients' beliefs have an important influence on the clinical management of low back pain and healthcare professionals should be prepared to address these beliefs. There is still a gap in the literature about the influence of patients' perceptions of their clinical diagnosis on the severity of their pain experience and disability., Objectives: To identify the perceptions of patients with chronic non-specific low back pain regarding the influence of their clinical diagnosis on pain, beliefs, and daily life activities., Methods: Qualitative study of 70 individuals with chronic non-specific low back pain. A semi structured interview was conducted about patients' beliefs and perceptions regarding the influence of clinical diagnosis on their daily activities and pain intensity., Results: Most participants believed that higher number of different clinical diagnoses for the same individual may be associated with high pain intensity and disability for daily activities and that pain and injury are directly related. Patients beliefs were grouped into four main themes: (1) pain has multifactorial explanation in physical dimension; (2) improvement expectation is extremely low in patients with chronic pain; (3) clinical diagnosis influences pain and disability levels; (4) clinical diagnosis is extremely valued by patients., Conclusions: Patients believe that there is a strong relationship between structural changes in the lower back, pain, and daily life activities; thus, providing evidence of a strong influence of the biomedical model on their beliefs., Competing Interests: Conflicts of interest The authors report no conflicts of interest., (Copyright © 2021 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: The purpose of this study was to investigate the effectiveness of web-based pain education programs without clinical support in patients with musculoskeletal pain., Methods: PubMed, Scopus, CINAHL, Web of Science, Cochrane Library, and PsycINFO were searched from inception to February 2020. Included studies were randomized clinical trials in which people with musculoskeletal pain were allocated to an experimental group that received web-based pain education as a standalone approach. Three review authors performed data extraction. The PEDro (Physiotherapy Evidence Database) scale was used to assess the methodological quality of the studies. The primary outcomes were pain intensity and disability., Results: Six trials with a total of 1664 participants were included. There is moderate-quality evidence with a small effect size that web-based pain education programs, as a standalone approach, are better than minimal intervention (no intervention or booklets) for pain intensity (standardized mean difference [SMD] = -0.23; 95% CI = -0.43 to -0.04) in the short term and intermediate term (SMD = -0.26; 95% CI = -0.42 to -0.10). Regarding disability, there is low-quality evidence that web-based pain education programs are better than minimal intervention (SMD = -0.36; 95% CI = -0.64 to -0.07) in the short term. Web-based pain education added to usual care was no better than usual care alone in the intermediate or long term for primary outcomes., Conclusions: Web-based pain education for adults with musculoskeletal pain, as a standalone approach, was better than minimal intervention for pain intensity and disability in the short term, and for pain intensity in the intermediate term. Web-based pain education added to usual care did not provide additional benefits for primary outcomes in the intermediate or long term., Impact: Web-based pain education as a standalone intervention provided small improvements in pain intensity and disability in patients with chronic musculoskeletal pain. Poorly resourced settings and overburdened health systems should consider this delivery method in the management of chronic musculoskeletal pain., Lay Summary: If you have chronic musculoskeletal pain, your physical therapist might recommend web-based pain education as treatment to help you reduce pain intensity and disability., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objectives: We aim to determine the effectiveness of meditation for adults with non-specific low back pain., Methods: We searched PubMed, EMBASE, PEDro, Scopus, Web of Science, Cochrane Library, and PsycINFO databases for randomized controlled trials that investigated the effectiveness of meditation in adults with non-specific low back pain. Two reviewers rated risk of bias using the PEDro scale and the certainty of the evidence using the GRADE approach. Primary outcomes were pain intensity and disability., Results: We included eight trials with a total of 1,234 participants. Moderate-certainty evidence shows that meditation is better than usual care for disability at short-term (SMD = -0.22; 95% CI = -0.42 to -0.02). We also found that meditation is better than usual care for pain intensity at long-term (SMD = -0.28; 95% CI = -0.54 to -0.02). There is no significant difference for pain intensity between meditation and minimal intervention or usual care at short and intermediate-term. We did not find differences between meditation and minimal intervention for disability at intermediate-term or usual care in any follow-up period., Conclusions: We found small effect sizes and moderate-certainty evidence that meditation is slightly better than minimal intervention in the short-term for disability. Low-certainty of evidence suggests that meditation is slightly better than usual care for pain in the long-term. Meditation appears to be safe with most trials reporting no serious adverse events., (© 2021 Walter de Gruyter GmbH, Berlin/Boston.)

Background: The Choosing Wisely initiative aims to promote discussions among healthcare professionals and patients about low-value, or potentially harmful, health practices., Objectives: To describe the process of development of the Brazilian Choosing Wisely list for musculoskeletal physical therapy., Methods: The Brazilian Choosing Wisely list was developed in accordance with the recommendations of the American Board of Internal Medicine. A three-step procedure was used. First, an expert panel was selected, and a modified Delphi approach was used to obtain a list of evidence-based statements. Second, members of the research team performed content analysis. Third, a national survey was conducted to present selected statements to a sample of physical therapists. Participants were invited to vote considering the level of importance of selected statements for physical therapists and patients., Results: The expert panel comprised 17 physical therapists. The median age of the expert panel was 33 [interquartile range (IQR) 29 to 37; range 26 to 60] years and the median length of professional experience was 12 (IQR 10 to 18) years. A list of eight recommendations was presented to a national sample composed of 1127 physical therapists. The median length of professional experience of the national sample was 10 (IQR 5 to 15) years. Based on the number of votes, the five most important recommendations were included in the Brazilian Choosing Wisely list for musculoskeletal physical therapy. Descriptive and frequency analysis were used to report the results., Conclusion: The Brazilian Choosing Wisely list for musculoskeletal physical therapy provides an opportunity for physical therapists, patients, society and policy makers to collaboratively discuss tests and treatments that are unnecessary or potentially harmful., (Copyright © 2021 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

Objective: Investigation if emotional reactivity by measuring heart rate variability (HRV) and pressure pain sensitivity during a passive visualization task in participants with chronic low back pain (CLBP)., Materials and Methods: This case-control study was composed of 47 participants with CLBP and 47 asymptomatic participants. Both groups were submitted to a passive visualization task using 27 pictures from PHODA (Photograph Series of Daily Activities). HRV frequency domains were measured before, during, and after the task. Pressure pain threshold and pain intensity were also measured before and after the task., Results: The adjusted mean difference was statistically significant for HRV frequency domains during the visualization task, including low frequency [-5.92; 95% confidence interval (CI)=-9.60 to -2.23], high frequency (-0.71; 95% CI=-1.02 to -0.39), and low-frequency/high-frequency ratio (8.82; 95% CI=5.19 to 12.45). Pressure pain threshold decreased after the task in the CLBP group in all body sites, and pain intensity increased (-0.8; 95% CI=-1.16 to -0.39)., Discussion: Aversive environmental stimuli, such as visual cues, may generate defensive physiological reactions. HRV can provide a measure that reflects the perceptions of threat and safety in the environment. Participants with CLBP presented changes in sympathovagal balance during passive visualization of pictures of daily activities, higher pain sensitivity, and high pain intensity when they were exposed to a passive visualization task using pictures of daily living that may arouse fears of harm., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Three-arm, parallel, randomized, placebo-controlled, assessor-blinded trial., Objective: To compare the immediate effect of manual therapy at the upper thoracic spine on the cardiovascular autonomic control of patients with musculoskeletal pain., Summary of Background Data: Musculoskeletal pain increases the risk of cardiovascular events. Thus, manual therapy applied to the upper thoracic region is likely efficient to improve the cardiac autonomic control., Methods: The study included 59 patients with musculoskeletal pain enrolled at an outpatient clinic. Participants were randomly assigned to spinal manipulation (n = 19), myofascial manipulation (n = 20), or placebo (n = 20) administered to the upper thoracic region. Resting heart rate variability provided indexes of the cardiac autonomic control, and the blood pressure response to the cold pressor test as a proxy of the sympathetic responsiveness to a stressor stimulus., Results: Groups were similar for baseline variables except for blood pressure. Two-way repeated-measures one-way analysis of covariance (ANCOVA) revealed that only spinal manipulation induced immediate increase of the square root of the mean squared differences of successive RR intervals (RMSSD), absolute (ms2), and normalized units (n.u.) of the high-frequency power (HF) as compared with pre-intervention evaluation, indicating an improvement in the parasympathetic activity to the heart. Normalized units of low-frequency power (LF) and the LF/HF ratio reduced after the spinal manipulation solely, suggesting a reduction of the sympathetic activity to the heart. There were no significant differences in the blood pressure responsiveness among the three treatments. There were no adverse events., Conclusion: In patients with musculoskeletal pain, spinal manipulation on the upper thoracic spine led to an immediate improvement in the resting cardiac autonomic control without an effect on the blood pressure responsiveness to a sympathoexcitatory stimulus. Myofascial manipulation or placebo did not change cardiovascular autonomic control.Level of Evidence: 2., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Despite the profound burden of disease, a strategic global response to optimise musculoskeletal (MSK) health and guide national-level health systems strengthening priorities remains absent. Auspiced by the Global Alliance for Musculoskeletal Health (G-MUSC), we aimed to empirically derive requisite priorities and components of a strategic response to guide global and national-level action on MSK health., Methods: Design: mixed-methods, three-phase design.Phase 1: qualitative study with international key informants (KIs), including patient representatives and people with lived experience. KIs characterised the contemporary landscape for MSK health and priorities for a global strategic response.Phase 2: scoping review of national health policies to identify contemporary MSK policy trends and foci.Phase 3: informed by phases 1-2, was a global eDelphi where multisectoral panellists rated and iterated a framework of priorities and detailed components/actions., Results: Phase 1: 31 KIs representing 25 organisations were sampled from 20 countries (40% low and middle income (LMIC)). Inductively derived themes were used to construct a logic model to underpin latter phases, consisting of five guiding principles, eight strategic priority areas and seven accelerators for action.Phase 2: of the 165 documents identified, 41 (24.8%) from 22 countries (88% high-income countries) and 2 regions met the inclusion criteria. Eight overarching policy themes, supported by 47 subthemes, were derived, aligning closely with the logic model.Phase 3: 674 panellists from 72 countries (46% LMICs) participated in round 1 and 439 (65%) in round 2 of the eDelphi. Fifty-nine components were retained with 10 (17%) identified as essential for health systems. 97.6% and 94.8% agreed or strongly agreed the framework was valuable and credible, respectively, for health systems strengthening., Conclusion: An empirically derived framework, co-designed and strongly supported by multisectoral stakeholders, can now be used as a blueprint for global and country-level responses to improve MSK health and prioritise system strengthening initiatives., Competing Interests: Competing interests: AMB reports grants from the Bone and Joint Decade Foundation during the conduct of the study. CHS reports grants from Curtin University during the conduct of the study. HS reports grants from the Bone and Joint Decade Foundation during the conduct of the study; personal fees from AbbVie outside the submitted work. JEJ reports personal fees from Curtin University during the conduct of the study. SP has nothing to disclose. JJY reports grants from the Danish Foundation for Chiropractic Research and Post-graduate Education, grants from Canadian Memorial Chiropractic College, grants from Ontario Chiropractic Association, grants from National Chiropractic Mutual Insurance Company Foundation, grants from the University of Southern Denmark Faculty Scholarship outside the submitted work. SS has nothing to disclose. DK-G has nothing to disclose. SMishrra reports grants from Curtin University during the conduct of the study. KEA reports personal fees from Amgen, personal fees from UCB, personal fees from FAN, personal fees from Astellas pharma, personal fees from Chugai pharma outside the submitted work. NA has nothing to disclose. JB has nothing to disclose. NB reports personal fees from Amgen, personal fees from Grunenthal, personal fees from Lilly, personal fees from Pfizer, personal fees from Sanofi, personal fees from Global Alliance for Patient Access outside the submitted work. FMB has nothing to disclose. RB reports personal fees from World Federation of Chiropractic outside the submitted work. DD has nothing to disclose. KED has nothing to disclose. LF has nothing to disclose. HEF has nothing to disclose. FG has nothing to disclose. SH has nothing to disclose. SAH has nothing to disclose. BH has nothing to disclose. AJ has nothing to disclose. MJ has nothing to disclose. AAK has nothing to disclose. JL has nothing to disclose. SMatsuda has nothing to disclose. AM reports grants, non-financial support and other from Merck KGaA; grants, non-financial support and other from Kolon TissueGene; grants, non-financial support and other from Merck KGaA; grants from Pfizer; grants from European Commission-Innovative Medicines Initiative (IMI); grants from European Union Structural Funds administered by the Research Council of Lithuania (Lietuvos mokslo taryba); grants from European Union Structural Funds administered by the Research Council of Lithuania (Lietuvos mokslo taryba); grants from European Commission-Framework 7 (FP7-HEALTH); grants from European Commission-Framework 7 (FP7-PEOPLE) Marie Skłodowska-Curie Program; personal fees from Galapagos-Servier; personal fees from Image Analysis Group (IAG); personal fees, non-financial support and other from Artialis SA; personal fees and other from Aché (Aché Laboratórios Farmacêuticos); personal fees and other from Abbvie; personal fees from Guidepoint Global,; personal fees from Alphasights; personal fees from Science Branding Communications; personal fees and non-financial support from Pfizer Consumer Healthcare; non-financial support from GSK Consumer Healthcare; personal fees and other from Flexion Therapeutics; personal fees from Pacira Biosciences; other from Genacol; personal fees, non-financial support and other from Sterifarma; other from Henry Stewart Talks; non-financial support from GlaxoSmithKline (GSK); grants from Versus Arthritis (Arthritis Research UK); personal fees and other from Korean Society for Osteoarthritis and Cartilage Repair; personal fees from American College of Rheumatology; personal fees and other from Spanish Society of Rheumatology; personal fees and other from Heilongjiang Rheumatology Association; personal fees and other from Zhujiang Hospital of Southern Medical University; non-financial support and other from International Cartilage Regeneration and Joint Preservation Society (ICRS); non-financial support and other from Osteoarthritis Research Society International (OARSI); non-financial support from AxDev International; other from Gordian Biotechnology; other from UNITY Biotechnology; personal fees and other from Bioiberica; other from The Dutch Arthritis Society (ReumaNederland); other from Kolon Life Science; personal fees from SANOFI; personal fees from European Commission; other from BRASIT/BRASOS, Brazil; other from GEOS, Brazil; other from European Orthopaedic Research Society (EORS); other from Brazilian Society of Rheumatology (SBR); other from Society for Osteoarthritis Research (SOAR), India; other from MCI Group, Geneva outside the submitted work. LMwaniki has nothing to disclose. MCN has nothing to disclose. MP has nothing to disclose. FJJR has nothing to disclose. ERS reports grants, personal fees and non-financial support from Abbvie; personal fees from Amgen; personal fees from BMS; grants from Glaxo; grants and personal fees from Janssen; personal fees from Lilly; grants and personal fees from Novartis; grants, personal fees and non-financial support from Pfizer; grants and personal fees from Roche; grants, personal fees and non-financial support from UCB outside the submitted work. HT reports having authored two books: Life Beyond the Carpal Tunnel (2007) and Holistic Pain Relief (2014). JW has nothing to disclose. DW has nothing to disclose. ADW has nothing to disclose. LMarch reports personal fees from Lilly, personal fees from Pfizer, personal fees from Abbvie, grants from Janssen outside the submitted work. LMarch is an executive member of OMERACT which receives funding from 30 different companies., (© 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: Heart rate variability (HRV) is an important physiological measure of the capacity for neurogenic homeostatic regulation, and an indirect measure of emotional processing. We aimed to investigate whether HRV parameters are altered in people with chronic low back pain when compared to healthy controls., Methods: We searched on PubMed, Scopus, CINAHL, Web of Science, Cochrane Library, and PsycINFO from inception to January 2018. The inclusion criteria were: patients with non-specific chronic low back pain, absence of radiculopathy, age from 18 to 65 years, and comparison with healthy controls. Data extraction was performed by two independent review authors. The methodological quality of the studies was assessed using the appraisal tool for cross-sectional studies., Results: After screening 2,873 potential articles, two studies met the inclusion criteria. Studies were composed of 153 patients with chronic low back pain and 62 healthy controls. An electrocardiogram was used to record HRV and linear methods (time and frequency) were used to analyze the results. The main findings indicate that patients with chronic low back pain have a significant reduction in HRV, with sympathetic predominance compared to healthy controls., Conclusions: There is limited evidence suggesting that chronic low back pain patients presented a lower vagal activity evidenced by HRV, when compared to healthy controls. The results of this systematic review should be interpreted with caution due to the restricted number of included studies, small sample sizes and different protocols used to measure HRV. The limited evidence about HRV alterations in low back pain also suggests the need of future studies to investigate if HRV parameters can be a useful measure in chronic pain samples or even if it can be used as an outcome in clinical trials aiming to investigate the effectiveness of interventions based on emotion regulation., (© 2021 Walter de Gruyter GmbH, Berlin/Boston.)

Study Design: Observational cross-sectional study., Objective: The aim of this study was to investigate the association between text neck and neck pain (NP) in adults., Summary of Background Data: It has been hypothesized that the inappropriate neck posture adopted when texting and reading on a smartphone, called text neck, is related to the increased prevalence of NP., Methods: The sample was composed of 582 volunteers aged between 18 and 65 years. Sociodemographics, anthropometrics, lifestyle, psychosocial, NP, and smartphone use-related questions were assessed by a self-reported questionnaire. Text neck was assessed by measuring the cervical flexion angle of the participants standing and sitting while typing a text on their smartphones, using the Cervical Range of Motion (CROM) device., Results: Multiple logistic regression analysis and linear regression analysis showed the cervical flexion angle of the standing participant using a smartphone did not associate with the prevalence of NP (odds ratio [OR] = 1.00; 95% confidence interval [CI]: 0.98-1.02; P = 0.66), NP frequency (OR = 1.01; 95% CI: 1.00-1.03; P = 0.056), or maximum NP intensity (beta coefficient = -5.195 × 10-5; 95% CI: -0.02 to 0.02; P = 0.99). Also, the cervical flexion angle of the sitting participant using the smartphone did not associate with NP (OR = 0.99; 95% CI: 0.98-1.01; P = 0.93), NP frequency (OR = 1.01; 95% CI: 0.99-1.02; P = 0.13), or maximum NP intensity (beta coefficient = 0.002; 95% CI: -0.002 to 0.02; P = 0.71)., Conclusion: Text neck was not associated with prevalence of NP, NP frequency, or maximum NP intensity in adults.Level of Evidence: 4., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The current study aimed to evaluate the concurrent validity and the diagnostic accuracy of the Central Sensitization Inventory (CSI) in detecting the impairment of the pain modulation in patients with chronic musculoskeletal pain., Methods: A cross-sectional study was conducted in 267 patients with chronic musculoskeletal pain enrolled consecutively in an outpatient department. The CSI (index method) were compared with the cold pressor test, which was the psychophysical test used to assess the conditioned pain modulation (CPM), (reference standard). Spearman's correlations assessed the concurrent validity, and measurements of the diagnostic accuracy were performed., Results: Ninety-three (34.8%) patients had CSI scores≥40. No significant correlation was found between CSI findings and the results of the CPT (dorsal forearm site or tibialis anterior site) was found. The cutoff point of 40 of the CSI showed values of sensitivity (35.1%, 95% CI: 22.6, 49.3) and specificity (65.2%, 95% CI: 58.4, 71.6) below 70%, and an accuracy of 59.1 (95% CI: 53.0, 65.1) when compared to the CPT to detect deficit. The ROC curve analysis yielded an area under the curve of 0.54 (95% CI: 0.45, 0.63, P>0.05)., Conclusions: The CSI is a useless instrument to detect the deficit in the CPM in patients with chronic musculoskeletal pain due to the absence of correlation with the psychophysical test result and the insufficient measurements of diagnostic accuracy., (Copyright © 2020 Société française de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.)

Objectives: Emotions are involved in the identification of safety cues in the environment, and are also related to social interaction through recognition of emotional facial expressions. Heart rate variability (HRV) can be an indicator of the adaptive response of the autonomic nervous system to stressful conditions, including pain. This study aimed to investigate the emotional processing in a sample of patients with chronic musculoskeletal by measuring the resting-state HRV and the ability to recognize facial emotion expressions., Methods: This cross-sectional study was composed of 40 participants with chronic musculoskeletal pain and 40 asymptomatic participants. Resting HRV was measured for 10 min. The facial emotion recognition task was presented in videos and included modification from a neutral expression to faces of fear, anger, sadness, happiness, and disgust. For the facial emotion recognition task, the hit rate (%) and response time for each emotional category were measured., Results: The symptomatic group had a mean high frequency (HF) lower (mean = 34.14; SD = 16.95; p<0.001) than the asymptomatic group (mean = 51.11; SD = 13.01; p<0.001). The emotional facial expressions of disgust ( H (1, 80)=7.82; p<0.01), anger ( H (1, 80)=13.56; p<0.01), sadness ( H (1, 80)=6.58; p=0.01), and happiness ( H (1, 80)=12.68; p<0.01) were those for which volunteers from the symptomatic group had a lower hit rate of correct answers compared to the asymptomatic group. The response time to corrected answers showed a major group effect ( F (1.77)=21.11; p<0.001) and emotional category ( F (4.308)=174.21; p<0.001), without presenting any interaction between the factors ( F (4.308)=0.446; p=0.775). The symptomatic group was slower to perform the task of identifying facial emotional expression (7.066 s; SD = 1.188) than the participants in the asymptomatic group (6.298 s; SD = 1.203) for all emotional categories., Conclusions: Participants with chronic musculoskeletal pain presented a lower vagal activity evidenced by HRV. Participants in the symptomatic group showed lower ability to recognize faces of disgust, anger, and sadness when compared to asymptomatic participants. Considering that individuals with low resting HF-HRV have difficulties with regulating their emotions, the lower vagal activity and lower ability to recognize faces of emotional expressions observed in chronic musculoskeletal pain may suggest alterations in emotional processing. This study may shed light on changes in the emotional processing and in the autonomic nervous system in this population., (© 2021 Walter de Gruyter GmbH, Berlin/Boston.)

Background: The identification of central sensitization (CS) is an important aspect in the management of patients with chronic musculoskeletal pain. Several methods have been developed, including clinical indicators and psychophysical measures. However, whether clinical indicators coincide with the psychophysical test of CS-related sign and symptoms is still unknown. Therefore, the present study aimed to analyze the diagnostic accuracy of the clinical indicators in identifying CS-related sign and symptoms in patients with musculoskeletal pain., Methods: One-hundred consecutive patients with musculoskeletal pain were included. Clinical indicators (index method) based on a combination of patient self-report pain characteristics and physical examination were used to identify the phenotype of patients with musculoskeletal pain and the predominance of the CS-related sign and symptoms. Conditioned pain modulation (CPM) was assessed by the Cold Pressor Test (reference standard), which is a psychophysical test used to detect impairment of CPM. Measurements of the diagnostic accuracy were performed., Results: Twenty-seven patients presented predominance of CS-related sign and symptoms in the assessment of the clinical indicators, and 20 had impairment of CPM. Clinical indicators showed high accuracy (75.0%; 95% confidence interval = 65.3 to 83.1), high specificity (80.0%; 95% confidence interval = 69.6 to 88.1), high negative predictive value (87.7%; 95% confidence interval = 81.2 to 92.1), and a relevant positive likelihood ratio (2.8, 95% confidence interval = 1.5 to 5.0) when compared to the Cold Pressor Test., Conclusion: Clinical indicators demonstrated a valuable tool for detecting the impaired CPM, which is a remarkable feature of the CS-related sign and symptoms. Clinicians are encouraged to use the clinical indicators in the management of patients with musculoskeletal pain.