Differences in the organization of the primary motor cortex in people with and without low back pain and associations with motor control and sensory tests.

Differences in organization of the primary motor cortex and altered trunk motor control (sensing, processing and motor output) have been reported in people with low back pain (LBP). Little is known to what extent these differences are related. We investigated differences in 1) organization of the primary motor cortex and 2) motor and sensory tests between people with and without LBP, and 3) investigated associations between the organization of the primary motor cortex and motor and sensory tests. We conducted a case-control study in people with (N=25) and without (N=25) LBP. The organization of the primary motor cortex (Center of Gravity (CoG) and Area of the cortical representation of trunk muscles) was assessed using neuronavigated transcranial magnetic stimulation, based on individual MRIs. Sensory tests (quantitative sensory testing, graphaesthesia, two-point discrimination threshold) and a motor test (spiral-tracking test) were assessed. Participants with LBP had a more lateral and lower location of the CoG and a higher temporal summation of pain. For all participants combined, better vibration test scores were associated with a more anterior, lateral, and lower CoG and a better two-point discrimination threshold was associated with a lower CoG. A small subset of variables showed significance. Although this aligns with the concept of altered organization of the primary motor cortex in LBP, there is no strong evidence of the association between altered organization of the primary motor cortex and motor and sensory test performance in LBP. Focusing on subgroup analyses regarding pain duration can be a topic for future research.

Illness perceptions in people with chronic and disabling non-specific neck pain seeking primary healthcare: a qualitative study.

BACKGROUND: Illness perceptions can affect the way people with musculoskeletal pain emotionally and behaviorally cope with their health condition. Understanding patients illness perceptions may help facilitate patient-centered care. The purpose of this study was to explore illness perceptions and the origin of those perceptions in people with chronic disabling non-specific neck pain seeking primary care. METHODS: A qualitative study using a deductive and inductive analytical approach was conducted in 20 people with persistent (> 3 months) and disabling (i.e., Neck Disability Index ≥ 15) neck pain. Using a semi-structured format, participants were interviewed about their illness perceptions according to Leventhal's Common Sense Model. Purposive sampling and member checking were used to secure validity of study results. RESULTS: Participants reported multiple symptoms, thoughts and emotions related to their neck pain, which continuously required attention and action. They felt trapped within a complex multifactorial problem. Although some participants had a broader biopsychosocial perspective to understand their symptoms, a biomedical perspective was dominant in the labelling of their condition and their way of coping (e.g., limiting load, building strength and resilience, regaining mobility, keep moving and being meaningful). Their perceptions were strongly influenced by information from clinicians. Several participants indicated that they felt uncertain, because the information they received was contradictory or did not match their own experiences. CONCLUSION: Most participants reported that understanding their pain was important to them and influenced how they coped with pain. Addressing this 'sense making process' is a prerequisite for providing patient-centered care.

Associations between facial expressions and observational pain in residents with dementia and chronic pain.

AIM: To identify specific facial expressions associated with pain behaviors using the PainChek application in residents with dementia. DESIGN: This is a secondary analysis from a study exploring the feasibility of PainChek to evaluate the effectiveness of a social robot (PARO) intervention on pain for residents with dementia from June to November 2021. METHODS: Participants experienced PARO individually five days per week for 15 min (once or twice) per day for three consecutive weeks. The PainChek app assessed each resident's pain levels before and after each session. The association between nine facial expressions and the adjusted PainChek scores was analyzed using a linear mixed model. RESULTS: A total of 1820 assessments were completed with 46 residents. Six facial expressions were significantly associated with a higher adjusted PainChek score. Horizontal mouth stretch showed the strongest association with the score, followed by brow lowering parting lips, wrinkling of the nose, raising of the upper lip and closing eyes. However, the presence of cheek raising, tightening of eyelids and pulling at the corner lip were not significantly associated with the score. Limitations of using the PainChek app were identified. CONCLUSION: Six specific facial expressions were associated with observational pain scores in residents with dementia. Results indicate that automated real-time facial analysis is a promising approach to assessing pain in people with dementia. However, it requires further validation by human observers before it can be used for decision-making in clinical practice. IMPACT: Pain is common in people with dementia, while assessing pain is challenging in this group. This study generated new evidence of facial expressions of pain in residents with dementia. Results will inform the development of valid artificial intelligence-based algorithms that will support healthcare professionals in identifying pain in people with dementia in clinical situations. REPORTING METHOD: The study adheres to the CONSORT reporting guidelines. PATIENT OR PUBLIC CONTRIBUTION: One resident with dementia and two family members of people with dementia were consulted and involved in the study design, where they provided advice on the protocol, information sheets and consent forms, and offered valuable insights to ensure research quality and relevance. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry number (ACTRN12621000837820).

Occurrence of corneal sub-epithelial microneuromas and axonal swelling in people with diabetes with and without (painful) diabetic neuropathy.

AIMS/HYPOTHESIS: Non-invasive in vivo corneal confocal microscopy is gaining ground as an alternative to skin punch biopsy to evaluate small-diameter nerve fibre characteristics. This study aimed to further explore corneal nerve fibre pathology in diabetic neuropathy. METHODS: This cross-sectional study quantified and compared corneal nerve morphology and microneuromas in participants without diabetes (n=27), participants with diabetes but without distal symmetrical polyneuropathy (DSPN; n=33), participants with non-painful DSPN (n=25) and participants with painful DSPN (n=18). Clinical and electrodiagnostic criteria were used to diagnose DSPN. ANCOVA was used to compare nerve fibre morphology in the central cornea and inferior whorl, and the number of corneal sub-epithelial microneuromas between groups. Fisher's exact tests were used to compare the type and presence of corneal sub-epithelial microneuromas and axonal swelling between groups. RESULTS: Various corneal nerve morphology metrics, such as corneal nerve fibre length and density, showed a progressive decline across the groups (p<0.001). In addition, axonal swelling was present more frequently (p=0.018) and in higher numbers (p=0.03) in participants with painful compared with non-painful DSPN. The frequency of axonal distension, a type of microneuroma, was increased in participants with painful and non-painful DSPN compared to participants with diabetes but without DSPN and participants without diabetes (all p≤0.042). The combined presence of all microneuromas and axonal swelling was increased in participants with painful DSPN compared with all other groups (p≤0.026). CONCLUSIONS/INTERPRETATION: Microneuromas and axonal swelling in the cornea increase in prevalence from participants with diabetes to participants with non-painful DSPN and participants with painful DSPN.

The effects of aerobic exercise on neuroimmune responses in animals with traumatic peripheral nerve injury: a systematic review with meta-analyses.

BACKGROUND: Increasing pre-clinical evidence suggests that aerobic exercise positively modulates neuroimmune responses following traumatic nerve injury. However, meta-analyses on neuroimmune outcomes are currently still lacking. This study aimed to synthesize the pre-clinical literature on the effects of aerobic exercise on neuroimmune responses following peripheral nerve injury. METHODS: MEDLINE (via Pubmed), EMBASE and Web of Science were searched. Controlled experimental studies on the effect of aerobic exercise on neuroimmune responses in animals with a traumatically induced peripheral neuropathy were considered. Study selection, risk of bias assessment and data extraction were performed independently by two reviewers. Results were analyzed using random effects models and reported as standardized mean differences. Outcome measures were reported per anatomical location and per class of neuro-immune substance. RESULTS: The literature search resulted in 14,590 records. Forty studies were included, reporting 139 comparisons of neuroimmune responses at various anatomical locations. All studies had an unclear risk of bias. Compared to non-exercised animals, meta-analyses showed the following main differences in exercised animals: (1) in the affected nerve, tumor necrosis factor-α (TNF-α) levels were lower (p = 0.003), while insulin-like growth factor-1 (IGF-1) (p < 0.001) and Growth Associated Protein 43 (GAP43) (p = 0.01) levels were higher; (2) At the dorsal root ganglia, brain-derived neurotrophic factor (BDNF)/BDNF mRNA levels (p = 0.004) and nerve growth factor (NGF)/NGF mRNA (p < 0.05) levels were lower; (3) in the spinal cord, BDNF levels (p = 0.006) were lower; at the dorsal horn, microglia (p < 0.001) and astrocyte (p = 0.005) marker levels were lower; at the ventral horn, astrocyte marker levels (p < 0.001) were higher, and several outcomes related to synaptic stripping were favorably altered; (4) brainstem 5-HT2A receptor levels were higher (p = 0.001); (5) in muscles, BDNF levels (p < 0.001) were higher and TNF-α levels lower (p < 0.05); (6) no significant differences were found for systemic neuroimmune responses in blood or serum. CONCLUSION: This review revealed widespread positive modulatory effects of aerobic exercise on neuroimmune responses following traumatic peripheral nerve injury. These changes are in line with a beneficial influence on pro-inflammatory processes and increased anti-inflammatory responses. Given the small sample sizes and the unclear risk of bias of the studies, results should be interpreted with caution.

Implementing PainChek and PARO to Support Pain Assessment and Management in Residents with Dementia: A Qualitative Study.

BACKGROUND: Pain is a common problem but often undiagnosed and untreated in people with dementia. AIMS: This study explored the experiences of residents with dementia, family, andformal carers with (1) pain assessment and management for residents with dementia; (2) the use of the PainChek app for pain assessment, and (3) the use of a social robot PARO for pain management in residents with dementia. DESIGN: A qualitative study. SETTINGS/PARTICIPANTS: Interviews were conducted with 13 residents withdementia, three family members, and 18 formal carers from a residential aged carefacility. METHOD: Residents with dementia interacted with PARO for 15 mins, five days perweek for three weeks. The PainChek app assessed pain levels before and after eachsession. After three-week intervention, individual interviews were conducted withresidents, family, and formal carers who experienced or observed the use of PainChekapp and PARO for residents. Interviews were audio-recorded, transcribed, andanalyzed using thematic analysis. RESULTS: Four themes were identified regarding pain in residents with dementia: (1) the impact, challenges and strategies of pain assessment and management; (2) benefits and barriers of using PainChek app to assess pain; (3) benefits of interacting with PARO to manage pain and behavioral symptoms; and (4) implementing PainChek app and PARO to support pain assessment and management in dementia care. CONCLUSIONS: Technology, such as PainChek and PARO, is promising to improve painassessment and reduce pain for people with dementia. Barriers to using technologyinclude limited staff training and the implementation of person-centered care.

Determining the level of cervical radiculopathy: Agreement between visual inspection of pain drawings and magnetic resonance imaging.

BACKGROUND AND AIMS: Pain drawings are commonly used in the clinical assessment of people with cervical radiculopathy. This study aimed to assess (1) the agreement of clinical interpretation of pain drawings and MRI findings in identifying the affected level of cervical radiculopathy, (2) the agreement of these predictions based on the pain drawing among four clinicians from two different professions (i.e., physiotherapy and surgery) and (3) the topographical pain distribution of people presenting with cervical radiculopathy (C4-C7). METHODS: Ninety-eight pain drawings were obtained from a baseline assessment of participants in a randomized clinical trial, in which single-level cervical radiculopathy was determined using MRI. Four experienced clinicians independently rated each pain drawing, attributing the pain distribution to a single nerve root (C4-C7). A post hoc analysis was performed to assess agreement. OUTCOME MEASURES: Percentage agreement and kappa values were used to assess the level of agreement. Topographic pain frequency maps were created for each cervical radiculopathy level as determined by MRI. RESULTS: The radiculopathy level determined from the pain drawings showed poor overall agreement with MRI (mean = 35.7%, K = -0.007 to 0.139). The inter-clinician agreement ranged from fair to moderate (K = 0.212-0.446). Topographic frequency maps revealed that pain distributions were widespread and overlapped markedly between patients presenting with different levels cervical radiculopathy. CONCLUSION: This study revealed a lack of agreement between the segmental level affected determined from the patient's pain drawing and the affected level as identified on MRI. The large overlap of pain and non-dermatomal distribution of pain reported by patients likely contributed to this result.

Classically conditioned modulation of pain depends on stimulus intensity.

Innocuous cues that become associated with pain can enhance pain. This is termed classically conditioned hyperalgesia. The size of this effect varies under different conditions. We aimed to test whether the sensitising effect of pain-associated cues depends on the intensity of the paired test stimulus. To do this, two virtual reality environments were paired with either painful or non-painful vibrotactile stimuli in a counterbalanced fashion. The differential effect of the two environments was evaluated using pain intensity ratings of paired electrocutaneous test stimuli at three different intensity levels. Forty healthy participants were included in the study; 30 participants experienced sufficient pain during the learning phase and were included in the main analysis. An effect of environment (p = 0.014) and interaction between environment and test stimulus intensity was found (p = 0.046). Only the most intense test stimulus was modulated by environment. While the effect was small, the results are consistent with the proposition that pain-associated cues may induce hyperalgesia to some degree, under certain conditions. In particular, results highlight the potential relevance of stimulus intensity during and after the initial painful experience. Further attention is needed to comprehensively understand the variables that impact classically conditioned hyperalgesia.

Preferred Self-Administered Questionnaires to Assess Resilience, Optimism, Pain Acceptance, and Social Support in People with Pain: A Modified Delphi Study.

OBJECTIVES: The plethora of self-administered questionnaires to assess positive psychosocial factors complicates questionnaire selection. This study aimed to identify and reach consensus on the most suitable self-administered questionnaires to assess resilience, optimism, pain acceptance and social support in people with pain. DESIGN: A three-round modified Delphi study. PARTICIPANTS: Forty international experts. METHODS: In Round 1, the experts suggested questionnaires deemed appropriate to assess resilience, optimism, pain acceptance and/or social support. In Round 2, experts indicated whether they considered the suggested questionnaires to be suitable (Yes/No/Don't know) to assess these psychosocial factors, taking into consideration content, feasibility, personal experience and the measurement properties which we provided for each questionnaire. Questionnaires that were considered suitable by the majority of experts (≥60%) were retained for Round 3. In Round 3, the suitability of each questionnaire was rated on a 0-10 Likert scale. Consensus was reached if ≥75% of experts rated the questionnaire ≥7. RESULTS: From the 67 questionnaires suggested in Round 1, one questionnaire could be recommended per domain. For resilience: Pain Resilience Scale; for optimism: Revised Version of the Life Orientation Test; for pain acceptance: 8-item and Revised Versions of the Chronic Pain Acceptance Questionnaire; for social support: Emotional Support Item Bank of the PROMIS tool. Consensus for these questionnaires was also reached in a sensitivity analysis which excluded the ratings of experts involved in the development, translation and/or validation of relevant questionnaires. CONCLUSION: We advocate the use of these recommended questionnaires so data can be compared and pooled more easily.

Machine Learning Can be Used to Predict Function but Not Pain After Surgery for Thumb Carpometacarpal Osteoarthritis.

BACKGROUND: Surgery for thumb carpometacarpal osteoarthritis is offered to patients who do not benefit from nonoperative treatment. Although surgery is generally successful in reducing symptoms, not all patients benefit. Predicting clinical improvement after surgery could provide decision support and enhance preoperative patient selection. QUESTIONS/PURPOSES: This study aimed to develop and validate prediction models for clinically important improvement in (1) pain and (2) hand function 12 months after surgery for thumb carpometacarpal osteoarthritis. METHODS: Between November 2011 and June 2020, 2653 patients were surgically treated for thumb carpometacarpal osteoarthritis. Patient-reported outcome measures were used to preoperatively assess pain, hand function, and satisfaction with hand function, as well as the general mental health of patients and mindset toward their condition. Patient characteristics, medical history, patient-reported symptom severity, and patient-reported mindset were considered as possible predictors. Patients who had incomplete Michigan Hand outcomes Questionnaires at baseline or 12 months postsurgery were excluded, as these scores were used to determine clinical improvement. The Michigan Hand outcomes Questionnaire provides subscores for pain and hand function. Scores range from 0 to 100, with higher scores indicating less pain and better hand function. An improvement of at least the minimum clinically important difference (MCID) of 14.4 for the pain score and 11.7 for the function score were considered "clinically relevant." These values were derived from previous reports that provided triangulated estimates of two anchor-based and one distribution-based MCID. Data collection resulted in a dataset of 1489 patients for the pain model and 1469 patients for the hand function model. The data were split into training (60%), validation (20%), and test (20%) dataset. The training dataset was used to select the predictive variables and to train our models. The performance of all models was evaluated in the validation dataset, after which one model was selected for further evaluation. Performance of this final model was evaluated on the test dataset. We trained the models using logistic regression, random forest, and gradient boosting machines and compared their performance. We chose these algorithms because of their relative simplicity, which makes them easier to implement and interpret. Model performance was assessed using discriminative ability and qualitative visual inspection of calibration curves. Discrimination was measured using area under the curve (AUC) and is a measure of how well the model can differentiate between the outcomes (improvement or no improvement), with an AUC of 0.5 being equal to chance. Calibration is a measure of the agreement between the predicted probabilities and the observed frequencies and was assessed by visual inspection of calibration curves. We selected the model with the most promising performance for clinical implementation (that is, good model performance and a low number of predictors) for further evaluation in the test dataset. RESULTS: For pain, the random forest model showed the most promising results based on discrimination, calibration, and number of predictors in the validation dataset. In the test dataset, this pain model had a poor AUC (0.59) and poor calibration. For function, the gradient boosting machine showed the most promising results in the validation dataset. This model had a good AUC (0.74) and good calibration in the test dataset. The baseline Michigan Hand outcomes Questionnaire hand function score was the only predictor in the model. For the hand function model, we made a web application that can be accessed via https://analyse.equipezorgbedrijven.nl/shiny/cmc1-prediction-model-Eng/. CONCLUSION: We developed a promising model that may allow clinicians to predict the chance of functional improvement in an individual patient undergoing surgery for thumb carpometacarpal osteoarthritis, which would thereby help in the decision-making process. However, caution is warranted because our model has not been externally validated. Unfortunately, the performance of the prediction model for pain is insufficient for application in clinical practice. LEVEL OF EVIDENCE: Level III, therapeutic study.

Feasibility study protocol of the PainChek app to assess the efficacy of a social robot intervention for people with dementia.

AIM: This study aims to test the feasibility of the PainChek app to assess pain for people with dementia living in residential aged care facilities (RACFs). It will also identify the optimal dosage and efficacy of a social robot (personal assistant robot [PARO]) intervention on chronic pain for people with dementia. DESIGN: This is a feasibility randomized controlled trial with three groups. METHODS: Forty-five residents living with dementia and chronic pain will be recruited from one RACF. The intervention consists of an individual 15-min non-facilitated session with a PARO robot twice a day (Group 1), a PARO robot once a day (Group 2), or a Plush-Toy (non-robotic PARO) once a day (Group 3) from Monday to Friday for 4 weeks. Participants will be followed at 4 and 8 weeks after baseline assessments. The primary outcome will be the feasibility of using the PainChek app to measure changes in pain levels before and after each session. Secondary outcomes include staff-rated pain levels, neuropsychiatric symptoms, quality of life and changes in psychotropic and analgesic medication use. Participants, staff and family perceptions of using PARO and the PainChek app will be collected after the 4-week intervention. DISCUSSION: This study will test the use of the PainChek app and PARO to improve pain management for people with dementia. Results from this study will help determine its usefulness, feasibility and acceptability for pain management in people with dementia living in RACFs. IMPACT: As pain is a significant problem for people with dementia, this project will generate evidence on the use of the PainChek to measure the efficacy of a social robot intervention that has the potential to improve the quality of pain care in people with dementia. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry number (ACTRN12621000837820) date registered 30/06/2021.

An individualized decision between physical therapy or surgery for patients with degenerative meniscal tears cannot be based on continuous treatment selection markers: a marker-by-treatment analysis of the ESCAPE study.

PURPOSE: Marker-by-treatment analyses are promising new methods in internal medicine, but have not yet been implemented in orthopaedics. With this analysis, specific cut-off points may be obtained, that can potentially identify whether meniscal surgery or physical therapy is the superior intervention for an individual patient. This study aimed to introduce a novel approach in orthopaedic research to identify relevant treatment selection markers that affect treatment outcome following meniscal surgery or physical therapy in patients with degenerative meniscal tears. METHODS: Data were analysed from the ESCAPE trial, which assessed the treatment of patients over 45 years old with a degenerative meniscal tear. The treatment outcome of interest was a clinically relevant improvement on the International Knee Documentation Committee Subjective Knee Form at 3, 12, and 24 months follow-up. Logistic regression models were developed to predict the outcome using baseline characteristics (markers), the treatment (meniscal surgery or physical therapy), and a marker-by-treatment interaction term. Interactions with p < 0.10 were considered as potential treatment selection markers and used these to develop predictiveness curves which provide thresholds to identify marker-based differences in clinical outcomes between the two treatments. RESULTS: Potential treatment selection markers included general physical health, pain during activities, knee function, BMI, and age. While some marker-based thresholds could be identified at 3, 12, and 24 months follow-up, none of the baseline characteristics were consistent markers at all three follow-up times. CONCLUSION: This novel in-depth analysis did not result in clear clinical subgroups of patients who are substantially more likely to benefit from either surgery or physical therapy. However, this study may serve as an exemplar for other orthopaedic trials to investigate the heterogeneity in treatment effect. It will help clinicians to quantify the additional benefit of one treatment over another at an individual level, based on the patient's baseline characteristics. LEVEL OF EVIDENCE: II.

Identifying the Most Important Confounders When Assessing the Association Between Low-Grade Systemic Inflammation and Musculoskeletal Pain: A Modified Delphi Study.

OBJECTIVE: The association between low-grade systemic inflammation and musculoskeletal pain may be influenced by multiple factors. However, little is known about the relative importance of these factors, and few studies account for them. This Delphi study aimed to reach consensus on the most important confounders which influence the association between low-grade systemic inflammation and musculoskeletal pain. METHODS: The panel consisted of 48 experts. In Round 1, the experts proposed what they believed were important confounders. In Round 2, the experts indicated for each confounder whether they believed it was important (yes/no). At least 50% of experts had to indicate the confounder was important to be considered in the final round. In Round 3, the experts rated the importance of each confounder on a 7-point Likert scale. Consensus was reached if ≥75% of the experts considered the factor either extremely or moderately important. RESULTS: In Round 1, 120 confounders were proposed, which were synthesized into 38 distinct factors. In Round 2, 33 confounders met the criterion to be considered important. In Round 3, consensus was reached for 14 confounders: acute illness/trauma, immune disease, medication use, endocrine, nutritional, or metabolic disease, other musculoskeletal conditions, age, handling of blood samples, sex, cancer, body composition, pregnancy, cardiovascular disease, physical activity, and pain characteristics. CONCLUSIONS: These findings provide insight in the complexity of the association between low-grade systemic inflammation and musculoskeletal pain. Some factors currently listed as confounders may be re-classified as moderators or mediators as insights progress.

High concurrent validity between digital and analogue algometers to measure pressure pain thresholds in healthy participants and people with migraine: a cross-sectional study.

BACKGROUND: Pressure pain thresholds (PPTs) are commonly assessed to quantify mechanical sensitivity in various conditions, including migraine. Digital and analogue algometers are used, but the concurrent validity between these algometers is unknown. Therefore, we assessed the concurrent validity between a digital and analogue algometer to determine PPTs in healthy participants and people with migraine. METHODS: Twenty-six healthy participants and twenty-nine people with migraine participated in the study. PPTs were measured interictally and bilaterally at the cephalic region (temporal muscle, C1 paraspinal muscles, and trapezius muscle) and extra-cephalic region (extensor carpi radialis muscle and tibialis anterior muscle). PPTs were first determined with a digital algometer, followed by an analogue algometer. Intraclass correlation coefficients (ICC3.1) and limits of agreement were calculated to quantify concurrent validity. RESULTS: The concurrent validity between algometers in both groups was moderate to excellent (ICC3.1 ranged from 0.82 to 0.99, with 95%CI: 0.65 to 0.99). Although PPTs measured with the analogue algometer were higher at most locations in both groups (p < 0.05), the mean differences between both devices were less than 18.3 kPa. The variation in methods, such as a hand-held switch (digital algometer) versus verbal commands (analogue algometer) to indicate when the threshold was reached, may explain these differences in scores. The limits of agreement varied per location and between healthy participants and people with migraine. CONCLUSION: The concurrent validity between the digital and analogue algometer is excellent in healthy participants and moderate in people with migraine. Both types of algometer are well-suited for research and clinical practice but are not exchangeable within a study or patient follow-up.

Using Visual Feedback Manipulation in Virtual Reality to Influence Pain-Free Range of Motion in People with Nonspecific Neck Pain.

BACKGROUND: Based on associative learning theories it is hypothesized that pain might be a conditioned response. In people with musculoskeletal pain, the occurrence of movement-induced pain might be a protective response, influenced by visual cues suggesting that the person is approaching a painful position. This study aimed to determine (1) whether the pain-free range of motion (ROM) increased and decreased when visual feedback understated or overstated true rotation in people with neck pain and (2) whether this effect was more pronounced if pain was chronic. METHOD: People with subacute and chronic nonspecific neck pain wore a VR-headset and rotated their head to the left and right until the onset of pain. Visual feedback about the amount of movement was either equal, 20% less, or 20% greater than their actual rotation. Maximal pain-free ROM was measured using the VR-headset sensors. Data were analyzed using a mixed-design ANOVA. RESULTS: There was no effect of visual feedback manipulation on pain-free ROM (P = 0.13) and no interaction effect between the visual feedback condition and duration of pain (P = 0.86). DISCUSSION: The inability to influence pain-free ROM by manipulating visual feedback in people with subacute or chronic neck pain does not support associative learning theories for the perception of neck pain.

How do people in China think about causes of their back pain? A predominantly qualitative cross-sectional survey.

BACKGROUND: Low back pain (LBP) is the second highest cause of health burden in China. Delayed recovery, poor clinical outcomes and persistence of LBP are associated with negative pain beliefs about LBP. Chinese philosophies are nested into the daily life of people in China, which is likely to influence pain beliefs. However, there is lack of knowledge about people's discourses regarding their LBP in China. The primary aim of this study was to explore the discourses underlying the beliefs of people in China about what causes their persistent or recurrent LBP. The secondary aim was to investigate the sources of these pain beliefs. METHODS: People (n = 152) from South Central, East and North Mainland China with LBP completed an online survey about what they believed caused their persistent or recurrent LBP and where these understandings came from. Potential causes of persistent or recurrent LBP were explored qualitatively using discourse analysis. The sources of these discourses were assessed by descriptive statistics with conventional content analysis. RESULTS: Five discourses were identified to underpin participants' beliefs about what caused their persistent or recurrent LBP, namely: (1) biomedical problems (66.4%), (2) unbalanced lifestyle (48.7%), (3) menstruation and 'kidney' status (9.2%), (4) the 'Five Elements' imbalance (7.9%), and (5) energy status (5.9%). Most participants responded that their pain beliefs were based on information derived from healthcare professionals (59.2%), followed by the internet (24.3%) and family (23.0%). CONCLUSIONS: People from moderately and well-developed parts of Mainland China think predominantly in line with a Western biomedical viewpoint about their LBP. Traditional Chinese medicine related pain beliefs mainly to the concept of 'balance' were evident on contemporary Chinese society's understandings of LBP. These cultural beliefs could be relevant to consider in LBP management and involve healthcare professionals, family and patient in this process.

Cross-cultural adaptation and validation of the Dutch language version of the Pictorial Fear of Activity Scale - Cervical.

BACKGROUND: The Pictorial Fear of Activity Scale-Cervical (PFActS-C) is a reliable and valid instrument to assess fear of movement in people with whiplash associated disorders. It is not available in Dutch and has not been evaluated in other neck pain populations. This study aimed to systematically translate the PFActS-C into Dutch and evaluate the psychometric properties of this Dutch Language Version (DLV) in people with non-specific neck pain. METHODS: The PFActS-C was translated according to international guidelines. Internal consistency, test-retest reliability, floor and ceiling effects, face validity and construct validity (convergent and discriminant validity by hypotheses testing and structural validity by confirmatory and exploratory factor-analyses) of the PFActS-C-DLV were tested in 125 people with non-specific neck pain. RESULTS: The PFActS-C-DLV showed good to excellent internal consistency (Cronbach's alpha: 0.98) and stability over time (ICC: 0.90 [95%CI: 0.82-0.93). Four out of five a priori formulated hypotheses regarding related (convergent validity) and unrelated (discriminant validity) constructs were confirmed. However, the confirmatory factor analysis could not confirm the expected 1-factor solution. Furthermore, the exploratory factor analyses revealed that also a higher factor solution would not lead to a good fit of the model. CONCLUSIONS: The PFActS-C-DLV is a reliable region-specific instrument for people with non-specific neck pain. The construct validity was supported, based on hypotheses testing. However, factor analyses could not confirm a 1-factor solution, so the underlying construct of the PFActS-C-DLV remains unclear. Given the PFActS-C's photographic format, we believe these findings also have relevance for the original English version.

Health-care providers' perspectives on factors influencing return-to-work after surgery for nontraumatic conditions of the upper extremity.

STUDY DESIGN: This study is a descriptive survey. INTRODUCTION: Health care providers (HCPs) are key stakeholders who facilitate workers' return to work (RTW) following upper extremity surgery. Hand therapists play a major role in this process, yet we do not know if and/or how their perspectives differ from other HCPs. PURPOSE OF THE STUDY: This study examined HCPs' opinion on factors that influence RTW after surgery for nontraumatic upper extremity conditions and whether HCPs from different disciplines differed in their opinion. METHODS: HCPs (occupational therapists, physiotherapists, hand therapists, exercise physiologists, psychologists, surgeons, and general practitioners) completed a survey rating 50 factors on a worker's ability to RTW. Each factor was scored using a 5-point Likert scale from "not" to "extremely" influential, which was later dichotomised. Agreement was indicated at 75%. The level of disagreement between disciplines was examined. RESULTS: Respondents (n = 787) identified 20 factors being influential on RTW. They are (in order from highest to lowest) poor pain coping (the highest, >85% of respondents), postoperative psychological state, RTW self-efficacy, employer/supervisor's support, employer's unwillingness for job modification, recovery expectations, job satisfaction, suitable duties availability, whether the job can be modified, and mood disorder diagnosis. There was agreement that two factors do not influence RTW, gender, and preemployment medical assessment. There was disagreement (P < .05) between HCP disciplines on six factors (obesity, comorbidities, doctors' RTW recommendation, diagnosis, fitness, income). There were no consistent patterns with respect to which professions disagreed across all six factors. Hand therapists differed from the other disciplines for three of the factors including diagnosis, comorbidities, and doctor's recommendation for RTW. DISCUSSION: The factors that stakeholders agreed as having the greatest influence were mainly related to the worker (pain and psychological factors) and the workplace and are amenable to RTW interventions. CONCLUSION: Interventions facilitating RTW and future research should consider the factors identified by HCPs in this study.

Fluctuations in local and widespread mechanical sensitivity throughout the migraine cycle: a prospective longitudinal study.

BACKGROUND: People with migraine have localised (i.e., cephalic) mechanical sensitivity. There is uncertainty regarding widespread (i.e., extra-cephalic) mechanical sensitivity and variations in mechanical sensitivity throughout the migraine cycle. Therefore, this study aimed (1) to comprehensively assess mechanical sensitivity in both cephalic and extra-cephalic regions during the preictal, ictal, postictal and interictal phases; and (2) to compare these findings with mechanical sensitivity at corresponding time-points and locations in healthy participants. METHODS: According to sample size calculations, 19 people with migraine and 19 matched healthy volunteers participated in a prospective longitudinal study. Pressure pain thresholds were evaluated in three cephalic regions (temporalis, upper trapezius and C1 paraspinal muscles) and two extra-cephalic regions (extensor carpi radialis and tibialis anterior muscle) with a digital algometer during the four phases of the migraine cycle in people with migraine and at corresponding intervals and locations in healthy participants. Linear mixed model analyses with a random intercept were used. RESULTS: People with migraine had increased mechanical sensitivity in cephalic and extra-cephalic regions in all phases of the migraine cycle compared to healthy participants. Furthermore, this mechanical sensitivity was more severe in the preictal, ictal and postictal phase compared to the interictal phase in cephalic and extra-cephalic regions. CONCLUSION: People with migraine have localised as well as widespread mechanical sensitivity compared to healthy participants. This sensitivity is even more pronounced immediately before, during and after a migraine attack.