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Over the last decade, the content, delivery and media of pain education have been adjusted in line with scientific discovery in pain and educational sciences, and in line with consumer perspectives. This paper describes a decade-long process of exploring consumer perspectives on pain science education concepts to inform clinician-derived educational updates (undertaken by the authors). Data were collected as part of a quality audit via a series of online surveys in which consent (non-specific) was obtained from consumers for their data to be used in published research. Consumers who presented for care for a persistent pain condition and were treated with a pain science education informed approach were invited to provide anonymous feedback about their current health status and pain journey experience 6, 12 or 18 months after initial assessment. Two-hundred eighteen consumers reported improvement in health status at follow-up. Results of the surveys from three cohorts of consumers that reported improvement were used to generate iterative versions of ‘Key Learning Statements’. Early iteration of these Key Learning Statements was used to inform the development of Target Concepts and associated community-targeted pain education resources for use in public health and health professional workforce capacity building initiatives. Perspective This paper reflects an explicit interest in the insights of people who have been challenged by persistent pain and then recovered, to improve pain care. Identifying pain science concepts that consumers valued learning provided valuable information to inform resources for clinical interactions and community-targeted pain education campaigns. Refereed/Peer-reviewed

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

Chronic low back pain (CLBP) is a leading cause of disability worldwide. Contemporary treatment of CLBP is suboptimal, with small-moderate effect sizes and high relapse rates. Virtual reality (VR) is an increasingly accessible technology that can improve adherence to exercise programs through gamification. Using VR to facilitate exercise adherence and enjoyment may improve the clinical outcomes. This study aimed to evaluate the effects of a gamified VR graded activity intervention in people with CLBP, using commercially available and bespoke VR programs. A sequentially replicated, multiple-baseline, randomized AB single-case experimental design was undertaken in 10 people with CLBP. Outcomes were assessed daily and included pain intensity (primary) and pain catastrophizing, pain-related fear, and anxiety/worry (secondary). The effect of the intervention on the primary outcome was evaluated using a multilevel-model, nonparametric randomization test. The VR graded activity intervention resulted in a significant reduction in pain intensity (effect estimate = −1.0, standard error = .27, P < .0011) with 4 participants achieving ≥30% pain reduction (minimum important change). There was a significant effect of the intervention on pain catastrophizing but not pain-related fear or anxiety/worry measures. These findings provide preliminary support for a VR graded activity program to reduce pain in people with CLBP. Refereed/Peer-reviewed

Refereed/Peer-reviewed Chronic low back pain is difficult to treat and despite increased spending on health services, clinical outcomes for people with low back pain have not improved. Innovative, large scale initiatives seem necessary to stem the cost of low back pain. Psychological health contributes to the development and persistence of chronic low back pain and psychological interventions are important in the management of low back pain. Given the contribution of psychological health to low back pain development and management, it raises the question; can we support psychological health in later life by bolstering emotional development in early life, and reduce the burden of this common condition? Positive early life experiences, including those induced by extended paid parental leave, could bolster emotional development and support the psychological health necessary to manage low backpain in later life. We present the current state of evidence demonstrating the potential value of increasing support for parent-child relationships in early life to reduce the burden of low back pain in future generations. The current evidence is limited to cross-sectional associations, but strong preclinical data clearly shows the potential negative impacts of maternal separation on rodent pup health that compels consideration in human populations.

Refereed/Peer-reviewed Background: Noninvasive electrical stimulation (ES) could have therapeutic potential in stroke recovery. However, there is no comprehensive evaluation of adverse events. This study systematically searched the literature to document frequency and prevalence of adverse events. A secondary aim was to explore associations between adverse events and ES parameters or participant characteristics. Methods: Databases were searched for studies evaluating ES in adults with stroke. All included studies were required to report on adverse events. Extracted data were: (1) study design; (2) adverse events; (3) participant characteristics; (4) ES parameters. Results: Seventy-five studies were included. Adverse events were minor in nature. The most frequently reported adverse events were tingling (37.3% of papers), burning (18.7%), headaches (14.7%) and fatigue (14.7%). Cathodal stimulation was associated with greater frequency of itching (p = .02), intensities of 1-2 mA with increased tingling (p = .04) and discomfort (p = .03), and current density = 0.37). Individual participants were more likely to report adverse events with increasing current density (r = 0.99, p = .001). Two severe adverse events were noted (a seizure and percutaneous endoscopic gastrostomy placement). Conclusion: ES appears safe in people with stroke as reported adverse events were predominantly minor in nature. An adverse events questionnaire is proposed to enable a more comprehensive and nuanced analysis of the frequency and prevalence of adverse events.

Objective To determine if impairment in motor imagery processes is present in Achilles tendinopathy (AT), as demonstrated by a reduced ability to quickly and accurately identify the laterality (left-right judgement) of a pictured limb. Additionally, this study aimed to use a novel data pooling approach to combine data collected at 3 different sites via meta-analytical techniques that allow exploration of heterogeneity. Design Multi-site case-control study. Methods Three independent studies with similar protocols were conducted by separate research groups. Each study-site evaluated left/right judgement performance for images of feet and hands using Recognise© software and compared performance between people with AT and healthy controls. Results from each study-site were independently collated, then combined in a meta-analysis. Results In total, 126 participants (40 unilateral, 22 bilateral AT cases, 61 controls) were included. There were no differences between AT cases and controls for hand image accuracy and reaction time. Contrary to the hypothesis, there were no differences in performance between those with AT and controls for foot image reaction time, however there were conflicting findings for foot accuracy, based on four separate analyses. There were no differences between the affected and unaffected sides in people with unilateral AT. Conclusions Impairments in motor imagery performance for hands were not found in this study, and we found inconsistent results for foot accuracy. This contrasts to studies in persistent pain of limbs, face and knee osteoarthritis, and suggests that differences in pathoetiology or patient demographics may uniquely influence proprioceptive representation.

In this case report, we used virtual reality (VR) to explore pain evoked by only the appearance of being touched (rather than actually being touched) in a person with complex regional pain syndrome type II. Furthermore, we explored the degree to which this visually evoked pain could be extinguished by applying exposure principles in VR. In stage 1, we identified 4 specific scenarios where pain was triggered by visually simulated touch (without physical stimulation) and used these scenarios to quantify baseline sensitivity to visuotactile stimulation. In stage 2, the patient undertook a 12-week virtual exposure program, and the visual triggers were reassessed 3 weeks after the commencement and immediately upon completion of the program. At baseline, severe pain and a profound cold sensation were immediately and consistently evoked in concert with visually simulated touch. At 12-week follow-up, only one of the initially provocative visual stimuli triggered pain and only after 60 seconds of repeated stimulation. Unfortunately, the transfer of desensitisation from VR to the real world was limited. This case report describes the phenomena of visually evoked pain. Moreover, it describes the near complete extinguishing of visually evoked pain through virtual graded exposure. How improvements gained in VR might be better transferred to real-word improvements merits further investigation.

Background There is evidence that people with persistent shoulder pain exhibit findings consistent with the presence of sensorimotor dysfunction. Sensorimotor impairments can manifest in a variety of ways, and further developing our understanding of sensorimotor dysfunction in shoulder pain may improve current models of care. The Fremantle Back Awareness Questionnaire (FreBAQ) has been developed to assess disturbed body perception specific to the back. The purpose of the present study was to develop a shoulder-specific self-perception questionnaire and evaluate the questionnaire in people with persistent shoulder pain. Methods The Fremantle Shoulder Awareness Questionnaire (FreSHAQ-J) was developed by modifying the FreBAQ. One hundred and twelve consecutive people with persistent shoulder pain completed the FreSHAQ-J. Thirty participants completed the FreSHAQ-J again two-weeks later to assess test-retest reliability. Rasch analysis was used to assess the psychometric properties of the FreSHAQ-J. Associations between FreSHAQ-J total score and clinical status was explored using correlational analysis. Results The FreSHAQ-J has acceptable category order, unidimensionality, no misfitting items, and excellent test-retest reliability. The FreSHAQ-J was moderately correlated with disability and pain catastrophization. Conclusions The FreSHAQ-J fits the Rasch measurement model well and is suitable for use with people with shoulder pain. Given the relationship between the FreSHAQ-J score and clinical status, change in body perception may be worth assessing when managing patients with shoulder pain.

Background and objective: This systematic, rapid review aimed to critically appraise and synthesize the recent literature (2014–2019) evaluating the incidence and prevalence of post-amputation phantom limb pain (PLP) and sensation (PLS). Databases and data treatment: Five databases (Medline, Embase, Emcare, PsychInfo, Web of Science) and Google Scholar were searched, with two independent reviewers completing eligibility screening, risk of bias assessment and data extraction. Results: The search identified 1,350 studies with 12 cross-sectional and 3 prospective studies included. Studies evaluated traumatic (n = 5), atraumatic (n = 4), and combined traumatic/atraumatic (n = 6) amputee populations, ranging from 1 month to 33 years post-amputation. Study heterogeneity prevented data pooling. The majority of studies had a high risk of bias, primarily due to limited generalizability. Three studies evaluated PLP incidence, ranging from 2.2% (atraumatic; 1 month) to 41% (combined; 3 months) and 82% (combined; 12 months). Only one study evaluated PLS/telescoping incidence. Across contrasting populations, PLP point prevalence was between 6.7%–88.1%, 1 to 3-month period prevalence was between 49%-93.5%, and lifetime prevalence was high at 76%–87%. Point prevalence of PLS was 32.4%-90%, period prevalence was 65% (1 month) and 56.9% (3 months), and lifetime prevalence was 87%. Telescoping was less prevalent, highest among traumatic amputees (24.6%) within a 1-month prevalence period. Variations in population type (e.g. amputation characteristics) and incidence and prevalence measures likely influence the large variability seen here. Conclusions: This review found that lifetime prevalence was the highest, with most individuals experiencing some type of phantom phenomena at some point post-amputation. Significance: This systematic rapid review provides a reference for clinicians to make informed prognosis estimates of phantom phenomena for patients undergoing amputation. Results show that most amputees will experience phantom limb pain (PLP) and phantom limb sensations (PLS): high PLP incidence 1-year post-amputation (82%); high lifetime prevalence for PLP (76%–87%) and PLS (87%). Approximately 25% of amputees will experience telescoping. Consideration of individual patient characteristics (cause, amputation site, pre-amputation pain) is pertinent given their likely contribution to incidence/prevalence of phantom phenomena. Refereed/Peer-reviewed

Background: Burning mouth syndrome (BMS) is a chronic pain disorder affecting the oral cavity. Previous work has shown promising analgesic results of bodily illusions in other chronic pain conditions. The aim of this proof‐of‐concept, pilot study was to investigate whether bodily illusions reduce pain in BMS patients. Methods: Nine participants diagnosed with BMS underwent bodily illusions using a MIRAGE‐mediated reality system. All participants completed 4 conditions and performed standardised movements of the tongue. First, a baseline condition was performed while the tongue was viewed at normal size and colour. Then, three conditions were performed in random order: resizing shrink, colour‐based (blue tongue), and incongruent movement illusions. During each condition, participants rated overall pain intensity as well as the intensity of burning pain/sensation on the tongue. Results: There was no difference in overall pain intensity ratings between conditions. However, a significant effect of condition was found for burning pain/sensation of the tongue. The colour illusion significantly reduced burning pain compared with baseline (MD = ‐12.8, 95% CI ‐20.7 to ‐4.8), corresponding to an average pain reduction of 32%. Exploratory analyses showed the colour illusion also significantly reduced pain compared with the shrink illusion (MD = ‐11.7, 95% CI ‐22.2 to ‐1.1). Conclusion: Using visual illusions to change tongue colour to blue resulted in significant reductions in burning pain/sensations in BMS patients for the duration of the illusion. This proof‐of‐concept study suggests that BMS patients may benefit from bodily illusions, and supports additional research using larger samples and more comprehensive control conditions. Refereed/Peer-reviewed

Background: Negative experiences of needle procedures in childhood can lead to medical avoidance and vaccine hesitancy into adulthood. We evaluated the feasibility of two new interventions provided by clinical nurses to reduce the negative impact of vaccinations: divided attention (DA) and positive memory reframing (PMR). Methods: Children (8-12 years) were randomized into four groups: usual care (UC), DA, PMR or combined (DA + PMR). To evaluate feasibility, we undertook in-depth analysis of video-recorded interventions, nurse experiences (phone interviews) and child/parent memory recall of interventions (phone interviews at 2 weeks post-vaccination). Key clinical outcomes included child and parent ratings of needle-related pain intensity and fear assessed at baseline, immediately post-vaccination and 2 weeks post-vaccination (recalled). Results: A total of 54 child-parent dyads were screened, with 41 included (10/group, except PMR [n = 11]). The interventions were not always completed as intended: 10%-22% of participants received complete interventions and two had adverse events related to protocol breach. Preliminary within-group analyses showed no effects on child/parent pain ratings. However, children in DA + PMR had reduced recalled fear (p = 0.008), and PMR (p = 0.025) and DA + PMR (p = 0.003) had reduced fear of future needles. Parent ratings of child fear were also reduced immediately post-vaccination for UC (p = 0.035) and PMR (p = 0.035). Conclusions: The interventions were feasible, although enhanced nurse training is required to improve fidelity. Preliminary clinical results appear promising, particularly for reducing needle-related fear. Protocol registration: Protocol number ACTRN12618000687291 at ANZCTR.org.au. Significance: Two new nurse-led interventions to reduce negative impacts of vaccinations in children, divided attention and positive memory reframing, were feasible and may reduce needle-related fear. Nurses were able to deliver the interventions in various environments including non-clinical settings (schools). These interventions have potential to facilitate broader dissemination of vaccinations for children in a manner that minimizes distress. Refereed/Peer-reviewed

Refereed/Peer-reviewed Importance: The effects of altered neural processing, defined as altering neural networks responsible for perceptions of pain and function, on chronic pain remains unclear. Objective: To estimate the effect of a graded sensorimotor retraining intervention (RESOLVE) on pain intensity in people with chronic low back pain. Design, Setting, and Participants: This parallel, 2-group, randomized clinical trial recruited participants with chronic (>3 months) nonspecific low back pain from primary care and community settings. A total of 276 adults were randomized (in a 1:1 ratio) to the intervention or sham procedure and attention control groups delivered by clinicians at a medical research institute in Sydney, Australia. The first participant was randomized on December 10, 2015, and the last was randomized on July 25, 2019. Follow-up was completed on February 3, 2020. Interventions: Participants randomized to the intervention group (n = 138) were asked to participate in 12 weekly clinical sessions and home training designed to educate them about and assist them with movement and physical activity while experiencing lower back pain. Participants randomized to the control group (n = 138) were asked to participate in 12 weekly clinical sessions and home training that required similar time as the intervention but did not focus on education, movement, and physical activity. The control group included sham laser and shortwave diathermy applied to the back and sham noninvasive brain stimulation. Main Outcomes and Measures: The primary outcome was pain intensity at 18 weeks, measured on an 11-point numerical rating scale (range, 0 [no pain] to 10 [worst pain imaginable]) for which the between-group minimum clinically important difference is 1.0 point. Results: Among 276 randomized patients (mean [SD] age, 46 [14.3] years; 138 [50%] women), 261 (95%) completed follow-up at 18 weeks. The mean pain intensity was 5.6 at baseline and 3.1 at 18 weeks in the intervention group and 5.8 at baseline and 4.0 at 18 weeks in the control group, with an estimated between-group mean difference at 18 weeks of -1.0 point ([95% CI, -1.5 to -0.4]; P =.001), favoring the intervention group. Conclusions and Relevance: In this randomized clinical trial conducted at a single center among patients with chronic low back pain, graded sensorimotor retraining, compared with a sham procedure and attention control, significantly improved pain intensity at 18 weeks. The improvements in pain intensity were small, and further research is needed to understand the generalizability of the findings. Trial Registration: ANZCTR Identifier: ACTRN12615000610538.

Chronic low back pain (CLBP) is a debilitating and burdensome condition, and new treatment strategies are needed. This study aimed to evaluate (1) the feasibility of undertaking a controlled clinical trial investigating a novel intervention for people with CLBP: hypnotically reinforced pain science education, and (2) the acceptability of the intervention as rated by participants. A priori feasibility and intervention acceptability criteria were set. Twenty participants with CLBP were recruited and randomized to receive: (1) hypnotically delivered pain science education that utilizes hypnotic suggestions to enhance uptake of pain science concepts; or (2) pain science education with progressive muscle relaxation as an attention control. Twenty participants were recruited, however, not solely from the hospital waitlist as intended; community sampling was required (13 hospital, 7 community). Most criteria were met in the community sample but not the hospital sample. Protocol modifications are needed before progressing to a full scale randomized controlled trial for hypnotically reinforced pain science education. Improvements in relevant secondary outcomes paired with moderate-high treatment acceptability ratings are promising. Chronic low back pain (CLBP) is a debilitating and burdensome condition, and new treatment strategies are needed. This study aimed to evaluate (1) the feasibility of undertaking a controlled clinical trial investigating a novel intervention for people with CLBP: hypnotically reinforced pain science education, and (2) the acceptability of the intervention as rated by participants. A priori feasibility and intervention acceptability criteria were set. Twenty participants with CLBP were recruited and randomized to receive: (1) hypnotically delivered pain science education that utilizes hypnotic suggestions to enhance uptake of pain science concepts; or (2) pain science education with progressive muscle relaxation as an attention control. Twenty participants were recruited, however, not solely from the hospital waitlist as intended; community sampling was required (13 hospital, 7 community).Most criteria were met in the community sample but not the hospital sample. Protocol modifications are needed before progressing to a full scale randomized controlled trial for hypnotically reinforced pain science education. Improvements in relevant secondary outcomes paired with moderate-high treatment acceptability ratings are promising. Refereed/Peer-reviewed

Pain interventions typically include effortful exercise and long-term treatment – ie, short-term costs (effort) with delayed benefit (improved pain and/or function). Thus, understanding if long-term pain influences decision-making in context of delays and effort is essential given clear relevance to treatment uptake and/or adherence. We evaluated delay and effort attitudes in those experiencing chronic pain (n = 391) and in pain-free controls (n = 263). Additionally, we investigated the role of bodily sensation awareness and/or interpretation as potential contributing factors to altered decision-making. Volunteers completed three discounting questionnaires, assessing the influence of temporal delays (gains, losses) and effort on devaluation of monetary outcomes. Individuals with chronic pain had more short-sighted decisions for monetary gains, but not losses, and decreased willingness to undertake effort for monetary gains than the No Pain group. The Pain group had higher bodily sensation awareness and while this related to higher impulsivity, delay and effort discounting, neither awareness nor interpretation of bodily sensations interacted with pain levels or explained group differences in discounting behavior. These findings suggest that impaired delay and effort-based discounting is present in people with chronic pain, and that this may be driven by pain-induced changes, but not pain-induced enhancements in bodily sensation awareness and/or interpretation. Exploring the utility of interventions targeting discounting behavior is warranted. Data availability: Study materials are available here: https://osf.io/zexm7/?view_only=c9848597361c41808c612874da6f33b7 . Perspective People with chronic pain make more short-sighted decisions (prefer less reward sooner) and decreased willingness to undertake effort (prefer less reward with little effort) for monetary gains than people without pain. Interventions targeting discounting behavior may help improve both uptake and adherence for evidence-based, effortful treatments, such as exercise.

Body re-sizing illusions can profoundly alter perception of our own body. We investigated whether creating the illusion of a muscled and fit-looking back (Strong) influenced perceived back size, body ownership, and attitudes towards self-capacity during a lifting task. Twenty-four healthy male volunteers performed a standardised lifting task while viewing real-time (delay

Background Bodily state is theorised to play a role in perceptual scaling of the environment, whereby low bodily capacity shifts visuospatial perception, with distances appearing farther and hills steeper, and the opposite seen for high bodily capacity. This may play a protective role, where perceptual scaling discourages engaging with the environment when capacity is low. Methodology Our protocol was pre-registered via Open Science Framework (https://osf.io/6zya5/) with all amendments to the protocol tracked. We performed a systematic review and meta-analysis examining the role of bodily state/capacity on spatial perception measures of the environment. Databases (Medline, PsychINFO, Scopus, Embase, and Emcare) and grey literature were searched systematically, inclusive to 26/8/21. All studies were assessed using a customised Risk of Bias form. Standard mean differences and 95% CIs were calculated via meta-analysis using a random-effects model. Results A total of 8,034 studies were identified from the systematic search. Of these, 68 experiments (3,195 participants) met eligibility and were included in the review. These were grouped into the following categories: fatigue; pain; age; embodiment; body size/body paty size; glucose levels; fitness; and interoception, and interoceptive accuracy. We found low level evidence (limited studies, high risk of bias) for the effect of bodily state on spatial perception. There was consistent evidence that both glucose manipulations and age influence spatial perception of distances and hills in a hypothesised direction (lower capacity associated with increased distance and hill steepness). Mixed evidence exists for the influence of external loads, embodiment, body/body-part size manipulations, pain, and interoceptive accuracy. Evidence for fitness and/or fatigue influencing spatial perception was conflicting; notably, methodological flaws with fitness and fatigue paradigms and heterogenous spatial perception measures may underlie null/conflicting results. Conclusion We found limited evidence for bodily state influencing spatial perception of the environment. That all studies had high risk of bias makes conclusions about reported effects reflecting actual perceptual shifts (vs merely reflecting experimental demands or error due to inadequate study design) pre-emptive. Rigorous evaluation is needed to determine whether reported effects reflect more than bias (e.g., experimental demands, inadequate blinding). Future work using reliable measures of spatial perception, comprehensive evaluation of relevant confounders, and methodologically robust (and experimentally confirmed) bodily state experimental paradigms is warranted.

Supplemental Digital Content is Available in the Text. The present results support the coexistence of altered body image (subjective without objective swelling) and pain, disability, and maladaptive beliefs in people with knee osteoarthritis., Introduction: There are complex interactions between pain and perceptions of the painful body part in musculoskeletal disorders, and disruption of various body representations in people with chronic pain. Objectives: The purpose of this study was to investigate how frequently people with knee osteoarthritis (OA) complain of swelling without objective evidence of swelling, and describe the clinical characteristics of this population. Methods: Forty-six people with knee OA (68.1 ± 8.8 years) participated in this cross-sectional study. Subjective and objective swelling was evaluated by knee-specific body perception questionnaire and ultrasonography, respectively. Pain intensity, disability, pain-related beliefs, 2-point discrimination threshold, and quadriceps muscle strength were also evaluated. Results: Approximately 1/3 of participants (n = 15) had subjective feelings of knee swelling in the absence of objective swelling (S only). Fifteen participants had both subjective and objective knee swelling (S + O group) and 16 had neither subjective nor objective knee swelling (No S/O group). Participants in the S only group had similar pain or disability as those in the S + O group but had more severe pain or disability than those with in the No S/O group. Those in the S only group also had larger 2-point discrimination distance threshold at the medial knee (impaired tactile acuity) than those in the S + O group and had more dysfunctional pain catastrophizing and pain-related self-efficacy than both other groups. Conclusion: Our results suggest that about 30% of people with knee OA perceive swelling of the knee in the absence of any objective swelling and that this is accompanied by severe pain and functional disability. Considering altered body image of the knee may reveal relevant treatment-based subgroups in people with knee OA.

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

Background: There is a strong association between chronic pain and unhelpful pain cognitions. Educating patients on pain neuroscience has been shown to reduce pain catastrophization, kinesiophobia, and self-perceived disability. This study investigated whether a group-based pain neuroscience education (PNE) session influenced pain-related outcomes, and whether readiness to change moderated these outcomes. Method: In a pragmatic pre-post-intervention study using a convenience sample, adults with chronic pain participated in one, 90–120 minute PNE session. Pain-related outcomes (i.e. pain catastrophization, kinesiophobia, disability, and pain neuroscience knowledge) and the Pain Stage of Change Questionnaire (PSOCQ) were assessed at baseline and immediately post-intervention. Paired t-tests evaluated pre-post changes in outcomes, and linear regression examined the impact of PSOCQ score changes on PNE-induced changes in clinical outcomes. Results: Sixty-five participants were recruited. All outcomes showed positive intervention effects (p < .01). Relationships between changes in PSOCQ subscale scores and change in post-intervention pain-related outcomes were found; ‘Pre-Contemplation’ was positively associated with pain catastrophization (p = .01), and ‘Action’ was negatively associated with kinesiophobia (p = .03). Conclusion: Consistent with previous research, there were improvements in outcomes associated with chronic pain after PNE. Some of these improvements were predicted by changes in PSOCQ scores, however, these findings are preliminary and require further investigation using controlled research designs. Refereed/Peer-reviewed

Objective This proof-of-concept pilot study aimed to investigate if a visual illusion that altered the size and muscularity of the back could be embodied and alter perception of the back. Methods The back visual illusions were created using the MIRAGE multisensory illusion system. Participants watched real-time footage of a modified version of their own back from behind. Participants undertook one experimental condition, in which the image portrayed a muscled, fit-looking back (Strong), and two control conditions (Reshaped and Normal) during a lifting task. Embodiment, back perception as well as pain intensity and beliefs about the back during lifting were assessed. Results Two participants with low back pain were recruited for this study: one with altered body perception and negative back beliefs (Participant A) and one with normal perception and beliefs (Participant B). Participant A embodied the Strong condition and pain and fear were less and both perceived strength and confidence were more than for the Normal or the Reshaped condition. Participant B did not embody the Strong condition and reported similar levels of pain, fear strength and confidence across all three conditions. Discussion An illusion that makes the back look strong successfully induced embodiment of a visually modified back during a lifting task in a low back pain patient with altered body perception. Both participants tolerated the illusion, there were no adverse effects, and we gained preliminary evidence that the approach may have therapeutic potential.

Background Chronic low back pain (CLBP) is a global health problem associated with an increasing burden on individuals, health care systems, and society. Common treatments for people with CLBP produce, on average, small short-term improvements in pain and function compared with minimal care. The RESOLVE trial randomly allocated 276 people with CLBP to a new complex treatment strategy, pain education integrated with graded sensorimotor precision training (RESOLVE), or a sham control. The RESOLVE treatment was developed within a theoretical framework to target possible treatment mechanisms associated with CLBP development and persistence. Objective This protocol describes the planned evaluation of these proposed treatment mechanisms. Improved understanding of the mechanisms underpinning the RESOLVE treatment may guide its refinement and implementation. Methods We will use causal mediation analysis to evaluate the proposed treatment mechanisms, including pain self-efficacy, back beliefs, pain catastrophizing, kinesiophobia, back perception, tactile acuity, and movement coordination. The primary outcomes are pain intensity and function at 18 weeks following allocation. Data were collected blind to allocation and hypotheses at baseline (mediators, outcomes, confounders), end of treatment (mediators), and at 18 weeks following allocation (outcomes). We will test the robustness of our findings by conducting planned sensitivity analyses. Results Ethical approval was granted by the University of New South Wales Human Research Ethics Committee (HC15357). A total of 276 participants have been recruited from primary care practices and the community in Sydney, Australia. Conclusions The RESOLVE treatment constitutes a new paradigm for CLBP management with potentially wide-reaching implications. This mechanistic evaluation will provide evidence for the hypothesized treatment mechanisms and help explain why the treatment strategy did or did not have an effect on patient-reported outcomes. These results will help guide the treatment refinement and implementation. Trial Registration Australian and New Zealand Clinical Trials Registry ACTRN12615000610538; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368619&isReview=true International Registered Report Identifier (IRRID) DERR1-10.2196/26053

Pain education is a popular treatment approach for persistent pain that involves learning a variety of concepts about pain (ie, target concepts), which is thought to be an important part of recovery. Yet, little is known about what patients value learning about pain. A mixed-methods survey was conducted to identify pain concepts that were valued by people with persistent pain who improved after a pain science education intervention. An online survey was distributed to 123 people who were treated for persistent pain with a pain science education approach; responses of participants who self-identified as "improved" were analysed. Open-ended survey questions were analysed using reflexive thematic analysis and close-ended questions were analysed for frequency of responses. Each question-type was analysed separately, before integration for complementarity. We analysed the data of 97 participants. We constructed 3 themes from the open-ended questions. Pain does not mean my body is damaged (theme 1) captured the importance of abandoning preexisting ideas that pain indicated damage. Thoughts, emotions and experiences affect pain (theme 2) captured the value of recognising multifactorial influences on pain. I can retrain my overprotective pain system (theme 3) captured the importance of conceptualising pain as a heightened protective response that could be lessened. Responses from close-ended questions confirmed that the target concepts represented by these themes are among those most valued, although divergence with the qualitative data suggests differences between patient and clinician language. These data offer patient-centred conceptualizations and language that could assist in further refining pain education interventions Refereed/Peer-reviewed

Letter to the Editor-in-Chief in response to JOSPT article “Education With Therapeutic Alliance Did Not Improve Symptoms in Patients With Chronic Low Back Pain and Low Risk of Poor Prognosis Compar...

Successful management of tissue injury cannot rely solely on pain responses because tissue healing is not directly related to pain. Pain without identifiable pathology is common in athletes,1 and as a result medical labelling remains an ongoing challenge. Therefore, we argue that, for the benefit of athletes, there is an urgent need for a clear distinction between pain and injury (see Infographic).Synonymous use of pain and injury in research and clinical practice may negatively impact clinical management. First, benign and normal fluctuations in pain may be seen as signs of sports-related injury, which could impact performance negatively. Second, viewing all pain as a direct sign of tissue injury may lead to underprioritising of psychological and social aspects of return-to-sport. Third, athletes being told they are ‘injured’ can lead to unnecessary assessment and interventions,2 particularly when a clear clinical diagnosis is lacking yet the reports of pain remain severe. Last, when pain is linked to unconfirmed injury, fear and anxiety may be heightened. Indeed, current evidence shows fear avoidance, fear of reinjury and pain catastrophising are common in response to an injury in athletes.3 Thus, a clearer distinction between pain and injury, paired with a person-centred and educational approach, seems necessary.New terminologyGiven that (1) tissue injury is nearly always accompanied by pain (ie, consistent with injury models)4 and (2) pain is not always accompanied by evidence of tissue injury (ie, consistent with contemporary science models of pain as a marker of protection or nociplasticity),5 we propose two new semantic entities that may co-occur, yet also be operational for both clinical and research purposes: Sports-related injury and sports-related pain (see Infographic).Sports-related pain or injury: a spectrum, not a dichotomyHere, we propose three stereotypical cases, representing different aspects of the spectrum: (1) anterior cruciate ligament tear (confirmed sports-related injury with sports-related pain), (2) patellofemoral pain (sports-related pain during certain activities in the absence of definable sports-related injury) and (3) patella tendinopathy (sports-related pain and clinical evidence of sports-related injury). For all three cases, individually tailored information and management strategies targeted to the findings are essential for optimal outcomes and return-to-sport.Differentiating between sports-related injury and pain, and carefully considering the contribution of each, may lead to better care for all stakeholders (ie, athletes, clinicians, and researchers) in the sports medicine community.

Refereed/Peer-reviewed Clinicians have an increasing number of evidence-based interventions to treat pain in youth. Mediation analysis offers a way of investigating how interventions work, by examining the extent to which an intermediate variable, or mediator, explains the effect of an intervention. This systematic review examined studies that used mediation analysis to investigate mechanisms of interventions on pain-relevant outcomes for youth (3–18 years) with acute or chronic pain, and provides recommendations for future mediation research in this field. We searched five electronic databases for clinical trials or observational longitudinal studies that included a comparison group and conducted mediation analyses of interventions on youth and assessed pain outcomes. We found six studies (N = 635), which included a total of 53 mediation models examining how interventions affect pain-relevant outcomes for youth. Five studies were secondary analyses of randomized controlled trials of psychological interventions for chronic pain; one was a longitudinal observational study of morphine for acute pain. The pain conditions studied were irritable bowel syndrome, functional abdominal pain, juvenile fibromyalgia, mixed chronic pain, and post-operative pain. Fourteen putative mediators were tested, of which three partially mediated treatment effect; seven did not significantly mediate treatment effect and four had mixed results. Methodological and reporting limitations were common. There are substantial gaps in the field with respect to investigating, and therefore understanding, how paediatric interventions work.

Body-specific mental rotation is thought to rely upon internal representations of motor actions. Handedness is a source of distinctly different motor experience that shapes the development of such internal representations. Yet, the influence of handedness upon hand mental rotation has never been systematically evaluated. Five databases were searched for studies evaluating hand left/right judgement tasks in adults. Two independent reviewers performed screening, data extraction, and critical appraisal. Eighty-seven datasets were included, with 72 datasets pooled; all had unclear/high risk of bias. Meta-analyses showed that right-handers were faster, but not more accurate, than left-handers at hand mental rotation. A unique effect of handedness was found on performance facilitation for images corresponding to the dominant hand. Meta-analyses showed that right-handers were quicker at identifying images of right hands than left hands—a dominance advantage not evident in left-handers. Differing hand representations (more lateralised hand dominance in right-handers) likely underpin these findings. Given potential differences between hand preference and motor performance, future research exploring their distinct contributions to mental rotation is warranted. Refereed/Peer-reviewed

Supplemental Digital Content is Available in the Text. This feasibility study of contemporary pain science education to increase activity levels in people with painful knee osteoarthritis supports progression to a larger trial., Introduction: Nine of 10 people with knee osteoarthritis are inactive. Unhelpful pain beliefs may negatively influence physical activity levels. Targeting these unhelpful pain beliefs, through contemporary pain science education (PSE), may provide benefit. Objectives: To evaluate the feasibility of conducting a clinical trial to determine the effect of adding PSE (vs adding sham ultrasound) to an individualised, physiotherapist-led education and walking program in people with painful knee osteoarthritis. Methods: Twenty participants were randomised (1:1) into the PSE group or Control group, each receiving 4 in-person weekly treatments, then 4 weeks of at-home activities (weekly telephone check-in). Clinical outcomes and physical activity (7 days of wrist-worn accelerometry) were assessed at baseline, 4 (clinical outcomes only), 8, and 26 weeks. A priori feasibility criteria for recruitment, intervention adherence, viability of wrist-based accelerometry, and follow-up retention were set. Perceived intervention credibility, acceptability, and usefulness from participants and clinicians were assessed (ratings, written/verbal feedback). Results: Most feasibility criteria were met. On average, 7 adults/wk were eligible, with 70% recruited. Treatment compliance was high (in-person: 80% PSE; 100% Control; at-home: 78% PSE; 75% Control). Wrist-based accelerometry had >75% valid wear-time. Sufficient follow-up rates were not achieved (26 weeks: 65%). Participant and clinician feedback highlighted that PSE was too complex and did not match patient expectations of “physiotherapy”, that sham ultrasound was problematic (clinician), but that both treatments had high credibility, acceptability, and usefulness. Conclusions: Progression to a full trial is warranted. Strategies to increase participant retention, refine the PSE content/delivery, and replace/remove the sham intervention are required.

Refereed/Peer-reviewed We tested the hypotheses that rendering sensory input about hand location imprecise increases a classically conditioned pain expectancy effect, increases generalization of the effect to novel locations and reduces extinction of the effect. Forty healthy volunteers performed movements with their right hand along predefined paths. Each path passed through 2 locations that were defined as either i) the conditioned stimulus (CS+; paired with a painful unconditioned stimulus), or ii) unpaired (CS-). During acquisition phase, participants watched their hand as they moved it. Participants were randomly allocated to an Imprecise group, for whom visual feedback of the hand was offset 30 to 50 mm from its true location, or a Precise group, for whom vision was not disrupted. In the test phase, participants moved their hands to 5 locations--the CS+, CS- locations that lay between the 2 ("generalization stimuli"). Our primary hypothesis was supported--pain expectancy was greater at the CS+ location in the Imprecise group than in the Precise group (6.9 [SD = 1.9] vs 5.4 [SD = 2.5], P= .02). Pain expectancies generalized to novel locations similarly in both groups and there was no difference in extinction between groups. Our primary hypothesis was supported but our subsequent hypotheses were not. Perspective: We conditioned pain expectancy at a certain location of one hand, even though most participants were unaware of the contingency. Conditioned pain expectancy was greater when sensory information about location was less precise. This adds support to the possibility that associative learning may play a role in the progression of an acute pain episode to a more generalized pain disorder.