Pain Neuroscience Education for Acute Pain.

In musculoskeletal and sports medicine, pain has traditionally been linked to tissue injury, often assuming a linear correlation between tissue damage and pain intensity. However, modern pain science has illuminated the complexity of the human pain experience, incorporating psychosocial elements, nervous system sensitization, immune responses, and structural changes in the brain as factors. This contemporary understanding of pain has proven highly beneficial for both clinicians treating individuals in pain and those experiencing pain. Pain neuroscience education (PNE) provides individuals in pain with an understanding of the underlying neurobiology and neurophysiology of their pain experience, which has been shown to result in decreased self-reported pain, reduced disability, the alleviation of fear and fear-avoidance behaviors, diminished pain catastrophizing, and improved movement. Currently, research on PNE predominantly focuses on interventions with individuals with persistent or chronic pain conditions. However, those who experience acute, sub-acute, and perioperative pain also have the potential for elevated levels of fear, fear-avoidance, and pain catastrophizing, indicating potential benefits from PNE. This invited commentary seeks to inform readers about the latest advancements in pain science and propose a conceptual model for delivering PNE in acute pain experiences. Level of Evidence: 5.

The correlation of trust as part of the therapeutic alliance in physical therapy and their relation to outcomes for patients with chronic low back pain.

BACKGROUND: Previous qualitative research has listed trust as a component of the therapeutic alliance in physical therapy. OBJECTIVE: Quantitatively correlate trust and therapeutic alliance in physical therapy care for patients with chronic low back pain. The secondary aim was to investigate the relation of trust and therapeutic alliance with outcomes over the course of treatment. METHODS: The Primary Care Assessment Survey was used to measure trust and the Working Alliance Inventory-Short Revised tool measured therapeutic alliance. The patient recorded these measures after the initial visit and at discharge. Self-report patient outcome measures for pain, function, and global rating of change were also measured at the same time points. RESULTS: A strong correlation (rs = 0.747 and rs = 0.801) was found between trust scores and therapeutic alliance measures post-initial visit and at discharge, respectively. In addition, there were moderate to strong correlations between trust and therapeutic alliance scores with the various improved outcome measures of pain, function, and global rating of change. CONCLUSION: There appears to be a connection between trust and therapeutic alliance along with improved patient outcomes related to higher trust and therapeutic alliance scores in a cohort with chronic low back pain.

Nociceptive, neuropathic, or nociplastic low back pain? The low back pain phenotyping (BACPAP) consortium's international and multidisciplinary consensus recommendations.

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.

Research Agenda for Physical Therapy From the American Physical Therapy Association.

Research agendas play an important role in directing scholarly inquiry in a field. The Research Agenda for Physical Therapy From the American Physical Therapy Association (APTA) outlines research priorities that are vital to advancing physical therapist practice and the profession. The development of the research agenda included multiple iterative steps and feedback from stakeholders. A research agenda subgroup (n = 6) of the APTA Scientific and Practice Affairs Committee (SPAC), with APTA staff support, gathered information on existing research agendas, developed draft priority descriptions, and gathered feedback via surveys. The subgroup first conducted an environmental scan of the research agendas in the physical therapy and rehabilitation fields. To gather information about research priorities, APTA's Technology and Organizational Performance department distributed a survey to 3 samples. APTA staff organized the feedback, and SPAC edited and synthesized a draft agenda. This draft was sent out in survey form to the original samples and to members of the APTA Academy of Research. Concurrently, a repeat environmental scan was conducted. A final draft of the research agenda was sent for final review to a smaller cohort (n = 95) that included content experts in each of the main categories of the agenda as identified by the APTA Academy of Research. The SPAC research agenda subgroup reviewed and incorporated the information into the final draft. The final research agenda includes priorities in topical areas (population health, mechanistic research, clinical research, education/professional development research, health services research, and workforce development) identified as key in the evolution of our profession. IMPACT: The Research Agenda for Physical Therapy From APTA identifies research priorities within the profession vital to advancing the practice and profession of physical therapy. The research agenda has 6 key areas of focus: population health research, mechanistic research, clinical research, education and professional development research, health services research, and workforce research. Researchers, funding agencies, and public policy makers can use the research agenda to concentrate research efforts around these areas.

The Biology of Chronic Pain and Its Implications for Pain Neuroscience Education: State of the Art.

Pain is an individualized experience for the person suffering from chronic pain. Significant strides have been made in the last few decades in understanding various biological changes that coincide with chronic pain. This state-of-the-art overview looks at the current evidence related to the biology of chronic pain and the implications these findings have on the delivery of pain neuroscience education (PNE). The paper summarizes the various (epi)genetic, neural, endocrine, and immune factors discovered and explored in the scientific literature concerning chronic pain. Each of these biological factors has various implications for the content and delivery of PNE. We discuss the future directions these biological factors have for the clinical implementation of PNE by linking the importance of behavior change, optimizing the learning environment, and using an individualized multimodal treatment approach with PNE. In addition, future directions for research of PNE based on these biological factors are provided with importance placed on individualized patient-centered care and how PNE can be used with traditional modes of care and growing trends with other care methods. PNE was originally and continues to be rooted in understanding chronic pain biology and how that understanding can improve patient care and outcomes.

Pain Neuroscience Education in Elementary and Middle Schools.

PURPOSE: The purpose of this study was to deliver pain neuroscience education (PNE) to participants in grades 3 to 8 to determine whether participants in these grades had positive shifts in pain knowledge and beliefs. METHODS: Three hundred twenty participants, grades 3 to 8, received a 1-time, 30-minute PNE lecture. The Neurophysiology of Pain Questionnaire and the Health Care Provider's Pain and Impairment Relationship Scale were administered before and after the PNE lecture. RESULTS: All grades improved in pain knowledge and beliefs. Higher-grade school participants (sixth to eighth grades) experienced larger shifts in pain knowledge and attitudes and beliefs than lower-grade (third to fifth grades) participants. CONCLUSION: PNE results in changes in pain knowledge and beliefs in school participants in grades 3 to 8.

Cross-sectional analysis of generational differences in pain attitudes and beliefs of patients receiving physical therapy care in outpatient clinics.

BACKGROUND: Musculoskeletal pain is a common reason to seek outpatient physical therapy care. Generational differences regarding attitudes and beliefs have been found in many areas, but it has not been explored regarding pain. OBJECTIVES: This study aimed to examine generational differences in attitudes and beliefs regarding pain and the potential differences between beneficial and non-beneficial treatment options in patients receiving care in outpatient physical therapy clinics. DESIGN: Cross-sectional descriptive survey. METHOD: A survey was developed to explore attitudes, beliefs, and treatment preferences. The survey was emailed out to past and current physical therapy patients as part of the customer satisfaction survey over a four-month period. RESULTS/FINDINGS: 2260 surveys were completed during the collection period. Generational differences were found between the different generational groups. Younger generations were more in line with current pain neuroscience, understanding that pain is normal and part of the survival mechanism and less likely to believe that pain meant something wrong with one's tissues. Younger generations also reported more agreeance to the ability to cope without medication. However, significant variations existed in treatment choices that were most beneficial and least beneficial between respondents. CONCLUSION: Generational differences do exist in some areas of pain attitudes and beliefs. Less variation was noted in treatment options between generations, but there were significant variations within all patient respondents.

The relationship between trust and outcomes during physical therapy care for chronic low back pain.

INTRODUCTION: Enhancing the therapeutic alliance has been associated with improved outcomes for patients with chronic low back pain (CLBP). Qualitatively trust has been described to be part of the therapeutic alliance, but it has not been measured quantitatively within the physical therapy literature. OBJECTIVE: Examine the relationship between trust and outcomes during physical therapy for CLBP. METHODS: Observational study of patients with CLBP being seen for physical therapy were assessed through self-report measures. The Primary Care Assessment Survey (PCAS) trust measurement scale was completed by patients at initial, post-initial, and discharge visit. These measurements were compared for correlations with patient reported outcome measures for pain and function recorded at initial visit and discharge. RESULTS: A convenience sample of 29 patients (49.3 ± 15 years old) with CLBP were measured. The PCAS showed correlations for changes in trust throughout treatment for improvements in pain and discharge pain rating. Average discharge pain rating correlated to changes in the PCAS (rs = -0.692, p < .001), with lower pain ratings relating to higher changes in trust over time. Average change in pain (rs = 0.745, p < .001) throughout treatment also correlated with higher changes in trust. Higher trust scores at discharge also correlated with improved Global Rating of Change and Oswestry Disability Index scores at discharge. The linear regression model showed adjusted R2 values for the trust scores and outcomes varied between 0.247 and 0.642. CONCLUSION: Both increases in trust throughout the treatment and end trust scores during physical therapy were related to improved outcomes for patients with CLBP.

The clinical impact of pain neuroscience continuing education on physical therapy outcomes for patients with low back and neck pain.

OBJECTIVES: Research suggests that attendance by physical therapists at continuing education (CE) targeting the management of low back pain (LBP) and neck pain does not result in positive impacts on clinical outcomes. The aim of this study was to determine if therapists attending a self-paced 3-hour online Pain Neuroscience Education (PNE) program was associated with any observed changes to patient outcomes and also clinical practice. METHODS: Participants were 25 different physical therapists who treated 3,705 patients with low back pain (LBP) or neck pain before and after they had completed an online PNE CE course. Change in outcomes measures of pain and disability at discharge were compared for the patients treated before and after the therapist training. Clinical practice patterns of the therapists, including total treatment visits, duration of care, total units billed, average units billed per visit, percentage of 'active' billing units and percentage of 'active and manual' billing units, were also compared for the patient care episodes before and after the therapist training. RESULTS: There was no significant difference for change in pain scores at discharge for patients treated after therapist CE training compared to those treated before regardless of the condition (LBP or neck pain). However, patients with LBP who were treated after therapist CE training did report greater improvement in their disability scores. Also after CE training, for each episode of care, therapists tended to use less total visits, billed fewer units per visit, and billed a greater percentage of more 'active' and 'active and manual' billing units. DISCUSSION: Attending an online 3-hour CE course on PNE resulted in improved disability scores for patients with LBP, but not for those with neck pain. Changes in clinical behavior by the therapists included using less visits, billing fewer total units, and shifting to more active and manual therapy interventions. Further prospective studies with control groups should investigate the effect of therapist CE on patient outcomes and clinical practice.

Comparison of reliability and efficiency of two modified two-point discrimination tests and two-point estimation tactile acuity test.

Objectives: Determine reliability and minimal detectible difference of two modified two-point discrimination (TPD) testing methods and explore reliability of newer tactile acuity test, two-point estimation (TPE) method.Design: Non-experimental observational reliability study.Setting: Community.Participants: Thirty-five (female = 25) healthy individuals average age 27.7 years (SD = 9.7).Intervention: Two modified methods (i.e., descending-ascending and descending with randomization) of TPD testing utilizing decreased runs of descending and ascending measurements were tested for inter-rater reliability and efficiency between two testers at three locations (neck, hand, and foot). The newer tactile acuity test of TPE was also performed between both examiners at the three location sites.Results: Inter-rater reliability (ICC 2, k) for the descending-ascending method was 0.75, 0.79, and 0.67 for the neck, hand, and foot, respectively. For the descending with randomization method, ICC values were 0.74, 0.50, and 0.69 for the three body regions respectively. The minimal detectable difference for the neck was 28.8 and 32.7 mm, hand 5.3 and 10.8 mm, and foot 12.3 and 12.4 mm for the descending-ascending and randomization methods. TPE showed poor reliability for neck and hand (0.27 and 0.15), but moderate reliability for the foot (0.67). Time to perform the TPD test were between 54 and 108 seconds, while TPE was 12 seconds.Conclusion: The modified TPD testing methods demonstrated similar reliability to previous research, even with reduced runs allowing for increased efficiency in performing the test. The TPE method showed poor reliability, so caution should be applied when using this method.

A Case-Series of Dry Needling as an Immediate Sensory Integration Intervention.

BACKGROUND: Chronic low back pain (CLBP) has been associated with altered cortical mapping in the primary somatosensory cortex. Various sensory discrimination treatments have been explored to positively influence CLBP by targeting cortical maps. OBJECTIVES: To determine if dry needling (DN) applied to patients with CLBP would yield changes in two-point discrimination (TPD) and left-right judgment (LRJ) tasks for the low back. Secondary measurements of pain and limited range of motion (ROM) was also assessed. METHODS: A sample of 15 patients with CLBP were treated with DN to their low back. Prior to and immediately after DN, TPD, LRJ tasks, low back pain, spinal ROM, and straight leg raise (SLR) were measured. RESULTS: Following DN, there was a significant (p < 0.005) improvement in LRJ for low back images in all measures, except accuracy for the right side. TPD significantly improved at the L3 segment with a moderate effect size. A significant improvement was found for pain and trunk ROM after DN with a large effect in changing pain of 3.33 points and improving SLR by 9.0 degrees on average, which exceeds the minimal detectable change of 5.7 degrees. CONCLUSIONS: This is the first study to explore if DN alters TPD and LRJ tasks in patients with CLBP. Results show an immediate significant positive change in TPD and LRJ tasks, as well as pain ratings and movement.

Evaluation is treatment for low back pain.

Objective: To investigate the effect of the examination process (history taking and physical examination) on pain and function. Methods: An observational cohort trial of patients presenting to outpatient physical therapy clinics for the first time with low back pain (n = 34, 57.7 ± 18.7 years, 53% female). A blinded investigator measured participants prior to the beginning of the initial evaluation and after each component of evaluation (history taking and physical examination). Another physical therapist provided normal history taking and physical examination as the patient case presented itself. Primary outcome measure was numeric pain rating scale (NPRS) for the low back and leg. Secondary outcomes and time during examination process and connection between PT and patient were also measured as potential confounders. Results: Participants showed a significant reduction in pain through just the history taking and physical exam for both the back with an NPRS reduction of 1.23 and the leg showing a 0.95 NPRS reduction. The most significant reduction occurs after history taking. Discussion: The evaluation process produced small, but significant, therapeutic effects related to pain, fear-avoidance, pain catastrophization, and functional measures of mobility and sensitivity. The therapist's report of connection with the patient did not alter the patient outcome.

Revisiting the Provision of Pain Neuroscience Education: An Adjunct Intervention for Patients but a Primary Focus of Clinician Education.

SYNOPSIS: Society is mired in a serious health care crisis regarding pain and opioid abuse. Pain neuroscience education (PNE) has gained support in the last 20 years as an intervention to help people manage chronic pain. In this Viewpoint, we argue that exercise and movement must be the primary intervention for chronic pain conditions, and that PNE or other adjunctive therapies should only be used if they can foster increased exercise and movement participation. Pain education should be the primary focus of a chronic pain management strategy for students and clinicians. It would help to advance knowledge and skills, and ultimately enhance care and outcomes for patients with chronic pain. J Orthop Sports Phys Ther 2021;51(2):57-59. doi:10.2519/jospt.2021.9804.

DUAL-TASK ASSESSMENT IMPLICATIONS FOR ANTERIOR CRUCIATE LIGAMENT INJURY: A SYSTEMATIC REVIEW.

BACKGROUND: Several systematic reviews have evaluated the role of dual-task assessment in individuals with concussion. However, no systematic reviews to date have investigated dual-task protocols with implications for individuals with anterior cruciate ligament (ACL) injury or ACL reconstruction (ACLR). PURPOSE: To systematically review the evidence on dual-task assessment practices applicable to those with ACL deficiency/ACLR, specifically with the aim to identify motor-cognitive performance costs. STUDY DESIGN: Systematic review. METHODS: A systematic literature review was undertaken on those with ACL-deficient or ACL-reconstructed knees performing dual-task activities. The following databases were searched from inception to June 8, 2018 including CINAHL, PsychInfo, PubMed, SPORTDiscus, Web of Science, and gray literature. Three primary search categories (knee, cognition, and motor task) were included. Only one reviewer independently performed the database search, data extraction, and scored each article for quality. All studies were assessed for quality and pertinent data were extracted, examined and synthesized. RESULTS: Ten studies were included for analysis, all of which were published within the prior ten years. Performance deficits were identified in those with either ACL deficiency or ACLR while dual-tasking, such as prioritization of postural control at the expense of cognitive performance, impaired postural control in single limb stance, greater number of cognitive errors, and increased step width coefficient of variation while walking. No studies examined those with prior ACL injury or ACLR during tasks that mimicked ACL injury mechanisms such as jump-landing or single-leg cutting. CONCLUSION: The results of the current systematic review suggests that postural control, gait, and/or cognitive deficits exist when evaluated under a dual-task paradigm in those with ACL deficiency or ACLR. This systematic review highlights the need for future research on dual-task assessment for individuals who have sustained an ACL injury or undergone ACLR, specifically utilizing more difficult athletic movements. LEVEL OF EVIDENCE: Level 3a.

THE INFLUENCE OF VISUAL FIXATION ON HOP TEST PERFORMANCE.

BACKGROUND: It has been recognized that anterior cruciate ligament (ACL) injuries typically occur when athletes are attending to a secondary task or object, including teammates, opponents, and/or a goal. Commonly applied tests after ACL injury include a series of hop tests to determine functional status, yet do not control for visual fixation. PURPOSE: To examine the influence of visual fixation during two functional hop tests in healthy individuals. STUDY DESIGN: Repeated measures. METHODS: Participants performed the crossover triple hop for distance (XHOP) on the left lower limb, and the medial triple hop for distance (MHOP) on the right. For the hop test only conditions, participants were not instructed where to fix their vision while performing the hop test. The visual fixation condition required participants to fix their vision on an alternating plus/minus sign at the center of a display monitor located in front of the participant while performing each hop test, respectively. A retest session occurred 48-72 hours after the initial test session in order to examine reliability. RESULTS: Thirty-four healthy adults (age: 24.0 ± 3.9 years) completed testing procedures, performing the XHOP and MHOP under standard and visual fixation conditions. Of those participants, twelve completed a retest session for reliability analysis. Hop distance was not altered by the addition of visual fixation (p = 0.27), with trivial effect sizes found across conditions (d = 0.02 - 0.07); however, the addition of visual fixation slightly improved within- and between-session intrarater reliability, standard error of measurement, and minimal detectable change of the MHOP. CONCLUSION: Hop distance during the XHOP and MHOP was not influenced by visual fixation. Measurement of both the XHOP and MHOP was reliable, but lacked precision. Measurement properties for the MHOP including within- and between-session reliability, standard error of measurement, and minimal detectable change improved slightly with the addition of visual fixation compared to normal MHOP procedures. LEVEL OF EVIDENCE: 2b.

The influence of center line width during the crossover hop test.

OBJECTIVES: To assess the influence of center line width on crossover hop for distance test (XHOP) performance. DESIGN: Repeated measures. SETTING: University laboratory. PARTICIPANTS: 33 physically active females without history of a ligamentous knee injury (age: 22.5 ± 2.3 years). MAIN OUTCOME MEASURES: Hop distance was measured during four XHOP conditions with variations in center line width: 2.54 cm (narrow), 15 cm (standard), 12.5% of the participants' height (HT1), and 25% of the participants' height (HT2). A repeated measures ANOVA was used to evaluate differences in hop distance for XHOP condition (narrow, standard, HT1, and HT2). RESULTS: Differences in hop distance were shown on XHOP condition (p < 0.001). Post hoc tests identified differences in hop distance between narrow and HT2 (p < 0.001, Effect size (ES) = 0.78), standard and HT2 (p < 0.001, ES = 0.57), and HT1 and HT2 (p < 0.001, ES = 0.58) conditions, respectively. CONCLUSIONS: No differences in hop distance were identified between narrow and standard center line width XHOP conditions in healthy females. Decreased hop distance was shown when center line width was normalized to 25% of participant height in comparison to all other XHOP conditions, with medium effect sizes. This study highlights hop distance outcomes based on different XHOP center line widths, normalizing the XHOP according to height, and potential implications for frontal plane knee loading during the XHOP in healthy individuals.

INCORPORATING A DUAL-TASK ASSESSMENT PROTOCOL WITH FUNCTIONAL HOP TESTING.

BACKGROUND: Hop tests are commonly used within a testing battery to assess readiness for return to sport after anterior cruciate ligament (ACL) injury, yet athletes still experience a high rate of re-injury. Simultaneous performance of a secondary task requiring cognitive processing or decision-making may test the athlete under more realistic contexts. PURPOSE: To examine a clinically feasible, dual-task assessment paradigm applied during functional hop tests in healthy individuals. STUDY DESIGN: Repeated measures. METHODS: Participants performed the crossover triple hop for distance (XHOP) and medial triple hop for distance test (MHOP) under three separate conditions: standard procedures and two dual-task protocols including the backward digit span memory task and a visuospatial recognition task. The visuospatial task involved briefly displaying an image consisting of 18 randomly placed red and blue circles on a screen, where the participant was asked to identify the number of red circles in each image. The backward digit span task was applied by introducing a sequence of random numbers to the participants, who were required to repeat the sequence in reverse order. Each motor and cognitive task was performed independently and simultaneously, in accordance with the dual-task paradigm. RESULTS: Thirty-four healthy participants (age: 24.0 ± 3.9 years) completed testing procedures. No differences in hop distance were observed with the simultaneous application of a cognitive task, with the exception of the backward digit span memory task resulting in decreased hop distance (p = 0.04, d = 0.14). There were no differences in cognitive accuracy according to hop test type, although the effect size was greater for the XHOP (p = 0.08, d = 0.49) compared to the MHOP (p = 1.0, d = 0.07). The dual-task protocol revealed good-excellent within- (ICC3,1 = 0.85 - 0.99) and between-session (ICC3,k = 0.94 - 0.99) intrarater reliability for hop distance across all dual-task conditions. The addition of a cognitive task to the XHOP and MHOP resulted in a lower standard error of measurement and decreased minimal detectable change, as compared to standard testing procedures. CONCLUSION: The simultaneous application of a cognitive task did not alter hop distance, with the exception of the backward digit span memory task resulting in decreased hop distance with a trivial effect size. There were no differences in cognitive accuracy according to task type (sitting, XHOP, MHOP). All combinations of dual-task assessment demonstrated good-excellent within- and between-session intrarater reliability among healthy individuals, but measurement precision was deficient. LEVEL OF EVIDENCE: 2b.

Behavior Change Following Pain Neuroscience Education in Middle Schools: A Public Health Trial.

Chronic pain and the opioid epidemic need early, upstream interventions to aim at meaningful downstream behavioral changes. A recent pain neuroscience education (PNE) program was developed and tested for middle-school students to increase pain knowledge and promote healthier beliefs regarding pain. In this study, 668 seventh-grade middle-school students either received a PNE lecture (n = 220); usual curriculum school pain education (UC) (n = 198) or PNE followed by two booster (PNEBoost) sessions (n = 250). Prior to, immediately after and at six-month follow-up, pain knowledge and fear of physical activity was measured. Six months after the initial intervention school, physical education, recess and sports attendance/participation as well as healthcare choices for pain (doctor visits, rehabilitation visits and pain medication use) were measured. Students receiving PNEBoost used 30.6% less pain medication in the last 6 months compared to UC (p = 0.024). PNEBoost was superior to PNE for rehabilitation visits in students experiencing pain (p = 0.01) and UC for attending school in students who have experienced pain > 3 months (p = 0.004). In conclusion, PNEBoost yielded more positive behavioral results in middle school children at six-month follow-up than PNE and UC, including significant reduction in pain medication use.