Efficacy of diadynamic currents as an adjunct to exercise to manage symptoms of knee osteoarthritis in adults: A randomized controlled clinical trial.

OBJECTIVE: To investigate the effect of diadynamic currents administered prior to exercises on pain and disability in patients with osteoarthritis of the knee. DESIGN: A randomized-controlled trial. SETTING: Special Rehabilitation Services in Taboão da Serra. PARTICIPANTS: Patients with bilateral knee osteoarthritis. INTERVENTION: Participants were randomly allocated to Group I (diadynamic currents and exercises; n = 30, 60 knees) or Group II (exercises alone; n = 30, 60 knees) and were treated three times a week for 8 weeks. MAIN OUTCOME MEASURES: The primary outcome measures were change in knee pain evaluated by visual analog scale and disability Index Score (Lequesne). Secondary outcomes included change in mobility (Timed Up and Go test), range of motion (goniometer), muscle strength (dynamometer), a composite score for pain and disability (Western Ontario and McMaster Universities Osteoarthritis questionnaire), and a drug diary to measure consumption of rescue pain medication (paracetamol). All measurements were collected at baseline, 8 weeks, and 6 months from baseline (follow-up). RESULTS: There were 60 participants with a mean (SD) age of 63.40 (8.20) years. Between-group differences in the follow-up (8 weeks and 6 months) were observed for pain at rest, pain during activities of daily living and disability. There was improvement in Group I that was maintained for the three variables 6 months after treatment. Mean difference for pain at rest was -3.08 points (95% confidence interval -4.13; -2.02), p < 0.01 with an effect size of 1.4; mean difference for pain during activities of daily living was -2.40 points (95% confidence interval -3.34; -1.45), p < 0.01 with an effect size of 1.24; and mean difference for disability was -4.08 points (95% confidence interval -5.89; -2.26), p < 0.01 with an effect size of 1.04. CONCLUSION: Patients with symptomatic knee osteoarthritis receiving 8 weeks of treatment with diadynamic currents as an adjunct to a program of exercises had significantly greater improvements in pain and disability than those receiving exercises alone. Beneficial effects were sustained for 6 months.

Age-related differences of vastus lateralis muscle morphology, contractile properties, upper body grip strength and lower extremity functional capability in healthy adults aged 18 to 70 years.

BACKGROUND: There is a lack of of cross-sectional research that has investigated muscle morphology, function, and functional capability in all age-bands of healthy adults. The primary aim of this study was to evaluate age-related differences in indices of vastus lateralis (VL) muscle morphology, function and functional capability in a sample of healthy males and females aged 18-70yrs. Secondary aims were to evaluate relationships between age and VL muscle morphology and function and functional capability. METHODS: B mode Ultrasonography and Tensiomyography were used to measure VL muscle thickness, pennation angle, fascicle length, and contractile properties in 274 healthy adults aged 18-70yrs. Measurements of grip strength and functional capability (1-min chair rise test) were also taken. Data analysis included descriptive statistics, correlations, one-way ANOVAs, and multiple regressions. RESULTS: Negative correlations were found between age and muscle thickness (rs = -.56), pennation angle (rs = -.50), fascicle length (rs = -.30), maximal displacement (rs = -.24), grip strength (rs = -.27) and the 1-min chair rise test (rs = -.32). Positive correlations were observed between age and the echo intensity of the muscle (rs = .40) and total contraction time (rs = .20). Differences in the indices of muscle health were noticeable between the 18-29 age band and the 50-59 and 60-70 age bands (p < 0.05). The interaction of age and level of physical activity predicted changes in the variables (r2 = .04-.32). CONCLUSION: Age-related differences in muscle health are noticeable at 50 years of age, and age-related differences are larger in females compared to males. It was suggested that the thickness of the VL changed the most with age across the adult lifespan and that physical activity likely acts to abate detrimental change.

Efficacy of prolonged application of low-level laser therapy combined with exercise in knee osteoarthritis: A randomized controlled double-blind study.

OBJECTIVES: To investigate the effect of prolonged low-level laser therapy application combined with exercise on pain and disability in patients with osteoarthritis of the knee. DESIGN: A randomized controlled trial. SETTING: Special rehabilitation services. SUBJECTS: Forty-three participants with knee osteoarthritis. INTERVENTION: Following initial assessment, participants were randomly allocated to the Laser group (n = 22, 44 knees) and received low-level laser therapy while the Placebo group (n = 21, 42 knees) received placebo therapy three times a week for 3 weeks. Both groups then received low-level laser therapy combined with exercise three times a week for the following 8 weeks. MAIN OUTCOME MEASURES: The primary outcome was change in knee pain and disability (Lequesne). Secondary outcomes included change in mobility (Timed Up and Go test), range of motion (goniometer), muscular strength (dynamometer), activity (Western Ontario and McMaster Universities Osteoarthritis questionnaire), and medication intake and relief. RESULTS: Mean (SD) age of participants was 63.02 (9.9) years. Pain scores at baseline, 3 weeks, 11 weeks, and 6 months follow-up were 9.1 (1.3), 2.6 (2.3), 0.2 (0.9), and 0.2 (0.8) for the Laser group and 9.5 (8.0), 7.7 (5.3), 5.6 (2.4), and 7.4 (5.0) for the Placebo group, respectively. Disability scores at baseline, 3 weeks, 11 weeks, and 6 months follow-up were 14.9 (4.7), 7.6 (4.8), 3.9 (4.2), and 3.5 (4.1) for the Laser group and 17.8 (14.7), 15.2 (11.5), 11.6 (6.4), and 15.8 (11.9) for the Placebo Group, respectively. CONCLUSION: In participants with osteoarthritis of the knee, the isolated application of low-level laser therapy in the initial 3 weeks and combined with exercises in the final 8 weeks reduced pain, disability, and intake of medication over a 6-month period.

Reconfiguring the biomedical dominance of pain: time for alternative perspectives from health promotion?

Strategies to reduce the burden of persistent pain in society are rooted in a biomedical paradigm. These strategies are located downstream, managing persistent pain once it has become a problem. Upstream activities that create social conditions to promote health and well-being are likely to help, yet health promotion discourse and research are lacking in pain literature. In this article, we argue that the subjective nature of pain has not sat comfortably with the objective nature of medical practice. We argue that the dominance of the biomedical paradigm, with a simplistic 'bottom-up' model of pain being an inevitable consequence of tissue damage, has been detrimental to the health and well-being of people living with persistent pain. Evidence from neuroscience suggests that bodily pain emerges as a perceptual inference based on a wide variety of contextual inputs to the brain. We argue that this supports community, societal and environmental solutions to facilitate whole-person care. We call for more salutogenic orientations to understand how people living with persistent pain can continue to flourish and function with good health. We suggest a need for 'upstream' solutions using community-based approaches to address cultural, environmental, economic and social determinants of health, guided by principles of equity, civil society and social justice. As a starting point, we recommend appraising the ways human society appreciates the aetiology, actions and solutions towards alleviating persistent pain.

Persistent pain is a major healthcare challenge. Most approaches to tackle pain involve medical treatments to relieve pain once it has become a problem. There has been little research into the role of activities that promote health and well-being on pain. We argue that there needs to be more research on how people living with persistent pain can continue to flourish and function with good health. We suggest that there needs to be more attention given to health promotion and community-based approaches to tackle persistent pain and that more research is needed on cultural, environmental, economic and social factors that influence pain.

Primary Periphyseal Stress Injuries of the Fingers in Adolescent Climbers: A Critical Review.

ABSTRACT: The worldwide rise in popularity of climbing and development of climbing as a competitive sport is reflected by its debut at the 2021 Summer Olympic Games in Tokyo. Digital primary periphyseal stress injuries in adolescent climbers may pose a significant risk to long-term skeletal health. The aim of this article is to critically review research on the diagnosis and management of primary periphyseal stress injuries of the fingers in adolescent climbers. We adopted a systematic approach to searching for relevant literature. Articles were identified after searches of the following electronic databases: Discover, Academic Search Complete, PubMed, Embase, SPORTDiscus, and ScienceDirect. Conclusive evidence suggests digital primary periphyseal stress injuries are a consequence of repetitive microtrauma. Pain reported by adolescent climbers on the dorsal aspect of the proximal interphalangeal joint should be investigated promptly to avoid serious negative consequences. Clinicians should be aware of the efficacy of imaging techniques to inform a clinical diagnosis. A conservative management approach is preferred but in rare cases surgical intervention may be necessary. A diagnostic and therapeutic algorithm for digital primary periphyseal stress injuries is presented.

Characterising the Features of 381 Clinical Studies Evaluating Transcutaneous Electrical Nerve Stimulation (TENS) for Pain Relief: A Secondary Analysis of the Meta-TENS Study to Improve Future Research.

Background and Objectives: Characterising the features of methodologies, clinical attributes and intervention protocols, of studies is valuable to advise directions for research and practice. This article reports the findings of a secondary analysis of the features from studies screened as part of a large systematic review of TENS (the meta-TENS study). Materials and Methods: A descriptive analysis was performed on information associated with methodology, sample populations and intervention protocols from 381 randomised controlled trials (24,532 participants) evaluating TENS delivered at a strong comfortable intensity at the painful site in adults with pain, irrespective of diagnosis. Results: Studies were conducted in 43 countries commonly using parallel group design (n = 334) and one comparator group (n = 231). Mean ± standard deviation (SD) study sample size (64.05 ± 58.29 participants) and TENS group size (27.67 ± 21.90 participants) were small, with only 13 of 381 studies having 100 participants or more in the TENS group. Most TENS interventions were 'high frequency' (>10 pps, n = 276) and using 100 Hz (109/353 reports that stated a pulse frequency value). Of 476 comparator groups, 54.2% were active treatments (i.e., analgesic medication(s), exercise, manual therapies and electrophysical agents). Of 202 placebo comparator groups, 155 used a TENS device that did not deliver currents. At least 216 of 383 study groups were able to access other treatments whilst receiving TENS. Only 136 out of 381 reports included a statement about adverse events. Conclusions: Clinical studies on TENS are dominated by small parallel group evaluations of high frequency TENS that are often contaminated by concurrent treatment(s). Study reports tended focus on physiological and clinical implications rather than the veracity of methodology and findings. Previously published criteria for designing and reporting TENS studies were neglected and this should be corrected in future research using insights gleaned from this analysis.

Resolving Long-Standing Uncertainty about the Clinical Efficacy of Transcutaneous Electrical Nerve Stimulation (TENS) to Relieve Pain: A Comprehensive Review of Factors Influencing Outcome.

Pain is managed using a biopsychosocial approach and pharmacological and non-pharmacological treatments. Transcutaneous electrical nerve stimulation (TENS) is a technique whereby pulsed electrical currents are administered through the intact surface of the skin with the intention of alleviating pain, akin to 'electrically rubbing pain away'. Despite over 50 years of published research, uncertainty about the clinical efficacy of TENS remains. The purpose of this comprehensive review is to critically appraise clinical research on TENS to inform future strategies to resolve the 'efficacy-impasse'. The principles and practices of TENS are described to provide context for readers unfamiliar with TENS treatment. The findings of systematic reviews evaluating TENS are described from a historical perspective to provide context for a critical evaluation of factors influencing the outcomes of randomized controlled trials (RCTs); including sample populations, outcome measures, TENS techniques, and comparator interventions. Three possibilities are offered to resolve the impasse. Firstly, to conduct large multi-centered RCTs using an enriched enrolment with randomized withdrawal design, that incorporates a 'run-in phase' to screen for potential TENS responders and to optimise TENS treatment according to individual need. Secondly, to meta-analyze published RCT data, irrespective of type of pain, to determine whether TENS reduces the intensity of pain during stimulation, and to include a detailed assessment of levels of certainty and precision. Thirdly, to concede that it may be impossible to determine efficacy due to insurmountable methodological, logistical and financial challenges. The consequences to clinicians, policy makers and funders of this third scenario are discussed. I argue that patients will continue to use TENS irrespective of the views of clinicians, policy makers, funders or guideline panel recommendations, because TENS is readily available without prescription; TENS generates a pleasant sensory experience that is similar to easing pain using warming and cooling techniques; and technological developments such as smart wearable TENS devices will improve usability in the future. Thus, research is needed on how best to integrate TENS into existing pain management strategies by analyzing data of TENS usage by expert-patients in real-world settings.

Does TENS Reduce the Intensity of Acute and Chronic Pain? A Comprehensive Appraisal of the Characteristics and Outcomes of 169 Reviews and 49 Meta-Analyses.

Background and Objectives: Uncertainty about the clinical efficacy of transcutaneous electric nerve stimulation (TENS) to alleviate pain spans half a century. There has been no attempt to synthesise the entire body of systematic review evidence. The aim of this comprehensive review was to critically appraise the characteristics and outcomes of systematic reviews evaluating the clinical efficacy of TENS for any type of acute and chronic pain in adults. Materials and Methods: We searched electronic databases for full reports of systematic reviews of studies, overviews of systematic reviews, and hybrid reviews that evaluated the efficacy of TENS for any type of clinical pain in adults. We screened reports against eligibility criteria and extracted data related to the characteristics and outcomes of the review, including effect size estimates. We conducted a descriptive analysis of extracted data. Results: We included 169 reviews consisting of eight overviews, seven hybrid reviews and 154 systematic reviews with 49 meta-analyses. A tally of authors' conclusions found a tendency toward benefits from TENS in 69/169 reviews, no benefits in 13/169 reviews, and inconclusive evidence in 87/169 reviews. Only three meta-analyses pooled sufficient data to have confidence in the effect size estimate (i.e., pooled analysis of >500 events). Lower pain intensity was found during TENS compared with control for chronic musculoskeletal pain and labour pain, and lower analgesic consumption was found post-surgery during TENS. The appraisal revealed repeated shortcomings in RCTs that have hindered confident judgements about efficacy, resulting in stagnation of evidence. Conclusions: Our appraisal reveals examples of meta-analyses with 'sufficient data' demonstrating benefit. There were no examples of meta-analyses with 'sufficient data' demonstrating no benefit. Therefore, we recommend that TENS should be considered as a treatment option. The considerable quantity of reviews with 'insufficient data' and meaningless findings have clouded the issue of efficacy. We offer solutions to these issues going forward.

Pain and Function in the Runner a Ten (din) uous Link.

A male runner (30 years old; 10-km time: 33 min, 46 sec) had been running with suspected insertional Achilles tendinopathy (AT) for ~2 years when the pain reached a threshold that prevented running. Diagnostic ultrasound (US), prior to a high-volume stripping injection, confirmed right-sided medial insertional AT. The athlete failed to respond to injection therapy and ceased running for a period of 5 weeks. At the beginning of this period, the runner completed the Victoria institute of sports assessment-Achilles questionnaire (VISA-A), the foot and ankle disability index (FADI), and FADI sport prior to undergoing an assessment of bi-lateral gastrocnemius medialis (GM) muscle architecture (muscle thickness (MT) and pennation angle (PA); US), muscle contractile properties (maximal muscle displacement (Dm) and contraction time (Tc); Tensiomyography (TMG)) and calf endurance (40 raises/min). VISA-A and FADI scores were 59%/100% and 102/136 respectively. Compared to the left leg, the right GM had a lower MT (1.60 cm vs. 1.74 cm), a similar PA (22.0° vs. 21.0°), a lower Dm (1.2 mm vs. 2.0 mm) and Tc (16.5 ms vs. 17.7 ms). Calf endurance was higher in the right leg compared to the left (48 vs. 43 raises). The athlete began a metronome-guided (15 BPM), 12-week progressive eccentric training protocol using a weighted vest (1.5 kg increments per week), while receiving six sessions of shockwave therapy concurrently (within 5 weeks). On returning to running, the athlete kept daily pain (Numeric Rating Scale; NRS) and running scores (miles*rate of perceived exertion (RPE)). Foot and ankle function improved according to scores recorded on the VISA-A (59% vs. 97%) and FADI (102 vs. 127/136). Improvements in MT (1.60 cm vs. 1.76 cm) and PA (22.0° vs. 24.8°) were recorded via US. Improvements in Dm (1.15 mm vs. 1.69 mm) and Tc (16.5 ms vs. 15.4 ms) were recorded via TMG. Calf endurance was lower in both legs and the asymmetry between legs remained (L: 31, R: 34). Pain intensity (mean weekly NRS scores) decreased between week 1 and week 12 (6.6 vs. 2.9), while running scores increased (20 vs. 38) during the same period. The program was maintained up to week 16 at which point mean weekly NRS was 2.2 and running score was 47.

A cross-sectional study to estimate the point prevalence of painful diabetic neuropathy in Eastern Libya.

BACKGROUND: Painful Diabetic Neuropathy (PDN) is a complication that affects up to one third of people living with diabetes. There is limited data on the prevalence of PDN from countries in the Middle East and North Africa. The aim of this study was to estimate the point prevalence of PDN in adults in Eastern Libya using the self-report Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) pain scale. METHODS: We invited patients attending the Benghazi Diabetes Centre who had diabetes for ≥ 5 years to take part in the study. Patients provided consent and completed the Arabic S-LANSS. Anthropometrics, marital status, socioeconomic and education information was recoded and fasting plasma glucose concentration determined. RESULTS: Four hundred and fifty participants completed the study (age = 19 to 87 years, BMI = 17.6 to 44.2 kg/m2, 224 women). One hundred and ninety five participants (43.3%) reported pain in their lower limbs in the previous 6 months and 190/195 participants (97.4%) reported a S-LANSS score of ≥ 12 suggesting they had neuropathic pain characteristics. Thus, 42.2% (190/450) of participants with diabetes were categorised as experiencing pain with neuropathic characteristics. Mean ± SD duration of diabetes for participants with PDN (20.4 ± 6.5 years) was significantly higher compared with those without PDN (11.1 ± 4.6 years). Participants with PDN smoked tobacco for more years than those without pain (7.9 ± 12.3 years versus 1.1 ± 3.9 years respectively); had significantly higher fasting plasma glucose concentration (143.6 ± 29.3 mg/dl versus 120.0 ± 17.3 mg/dl) and had a significantly higher levels of education and employment status. The most significant predictors of PDN were duration of diabetes (OR = 25.85, 95% CI = 13.56-49.31), followed by smoking for men (OR = 8.28, 95% CI = 3.53-9.42), obesity (OR = 3.96, 95% CI = 2.25-6.96) and high fasting plasma glucose concentration (OR = 3.51, 95% CI = 1.99-6.21). CONCLUSION: The prevalence of PDN in people with diabetes in Eastern Libya was 42.2%. Risk factors for developing PDN were high fasting plasma glucose concentration, long duration of diabetes, and higher level of educational and employment status.

Are changes in running economy associated with changes in performance in runners? A systematic review and meta-analysis.

Improvements in running economy (RE) are thought to lead to improvements in running performance (P). Multiple interventions have been designed with the aim of improving RE in middle and long-distance runners. The aim of this study was to assess the effect of interventions of at least 2-weeks' duration on RE and P and to determine whether there is a relationship between changes in RE (ΔRE) and changes in running performance (ΔP). A database search was carried out in Web of Science, Scopus and SPORTDiscus. In accordance with a PRISMA checklist 10 studies reporting 12 comparisons between interventions and controls were included in the review. There was no correlation between percentage ΔRE and percentage ΔP (r = 0.46, P = 0.936, 12 comparisons). There was a low risk of reporting bias but an unclear risk of bias for other items. Meta-analyses found no statistically significant differences between interventions and controls for RE (SMD (95% CI) = -0.37 (-1.43, 0.69), 204 participants, p = 0.49) or for P (SMD (95% CI) = -0.65 (-26.02, 24.72, 204 participants, p = 0.99). There is a need for studies of greater statistical power, methodological quality, duration and homogeneity of intervention and population. Standardised measures of performance and greater control over non-intervention training are also required.

The Landscape of Chronic Pain: Broader Perspectives.

Chronic pain is a global health concern. This special issue on matters related to chronic pain aims to draw on research and scholarly discourse from an eclectic mix of areas and perspectives. The purpose of this non-systematic topical review is to précis an assortment of contemporary topics related to chronic pain and its management to nurture debate about research, practice and health care policy. The review discusses the phenomenon of pain, the struggle that patients have trying to legitimize their pain to others, the utility of the acute-chronic dichotomy, and the burden of chronic pain on society. The review describes the introduction of chronic primary pain in the World Health Organization's International Classification of Disease, 11th Revision and discusses the importance of biopsychosocial approaches to manage pain, the consequences of overprescribing and shifts in service delivery in primary care settings. The second half of the review explores pain perception as a multisensory perceptual inference discussing how contexts, predictions and expectations contribute to the malleability of somatosensations including pain, and how this knowledge can inform the development of therapies and strategies to alleviate pain. Finally, the review explores chronic pain through an evolutionary lens by comparing modern urban lifestyles with genetic heritage that encodes physiology adapted to live in the Paleolithic era. I speculate that modern urban lifestyles may be painogenic in nature, worsening chronic pain in individuals and burdening society at the population level.

Acupuncture for the Relief of Chronic Pain: A Synthesis of Systematic Reviews.

Background and Objectives: It is estimated that 28 million people in the UK live with chronic pain. A biopsychosocial approach to chronic pain is recommended which combines pharmacological interventions with behavioural and non-pharmacological treatments. Acupuncture represents one of a number of non-pharmacological interventions for pain. In the current climate of difficult commissioning decisions and constantly changing national guidance, the quest for strong supporting evidence has never been more important. Although hundreds of systematic reviews (SRs) and meta-analyses have been conducted, most have been inconclusive, and this has created uncertainty in clinical policy and practice. There is a need to bring all the evidence together for different pain conditions. The aim of this review is to synthesise SRs of RCTs evaluating the clinical efficacy of acupuncture to alleviate chronic pain and to consider the quality and adequacy of the evidence, including RCT design. Materials and Methods: Electronic databases were searched for English language SRs and meta-analyses on acupuncture for chronic pain. The SRs were scrutinised for methodology, risk of bias and judgement of efficacy. Results: A total of 177 reviews of acupuncture from 1989 to 2019 met our eligibility criteria. The majority of SRs found that RCTs of acupuncture had methodological shortcomings, including inadequate statistical power with a high risk of bias. Heterogeneity between RCTs was such that meta-analysis was often inappropriate. Conclusions: The large quantity of RCTs on acupuncture for chronic pain contained within systematic reviews provide evidence that is conflicting and inconclusive, due in part to recurring methodological shortcomings of RCTs. We suggest that an enriched enrolment with randomised withdrawal design may overcome some of these methodological shortcomings. It is essential that the quality of evidence is improved so that healthcare providers and commissioners can make informed choices on the interventions which can legitimately be provided to patients living with chronic pain.

A Single Site Population Study to Investigate CYP2D6 Phenotype of Patients with Persistent Non-Malignant Pain.

Background and Objectives: Codeine requires biotransformation by the CYP2D6 enzyme, encoded by the polymorphic CYP2D6 gene, to morphine for therapeutic efficacy. CYP2D6 phenotypes of poor, intermediate, and ultra-rapid metabolisers are at risk of codeine non-response and adverse drug reactions due to altered CYP2D6 function. The aim of this study was to determine whether genotype, inferred phenotype, and urinary and oral fluid codeine O-demethylation metabolites could predict codeine non-response following a short course of codeine. Materials and Methods: There were 131 Caucasians with persistent pain enrolled. Baseline assessments were recorded, prohibited medications ceased, and DNA sampling completed before commencing codeine 30 mg QDS for 5 days. Day 4 urine samples were collected 1-2 h post morning dose for codeine O-demethylation metabolites analysis. Final pain assessments were conducted on day 5. Results: None of the poor, intermediate, ultra-rapid metabolisers and only 24.5% of normal metabolisers responded to codeine. A simple scoring system to predict analgesic response from day 4 urinary metabolites was devised with overall prediction success of 79% (sensitivity 0.8, specificity 0.78) for morphine and 79% (sensitivity 0.76, specificity 0.83) for morphine:creatinine ratio. Conclusions: In conclusion, this study provides tentative evidence that day 4 urinary codeine O-demethylation metabolites could predict non-response following a short course of codeine and could be utilised in the clinical assessment of codeine response at the point of care to improve analgesic efficacy and safety in codeine therapy. We offer a scoring system to predict codeine response from urinary morphine and urinary morphine:creatinine ratio collected on the morning of day 4 of codeine 30 mg QDS, but this requires validation before it could be considered for use to assess codeine response in clinical practice.

The Proportion of Lower Limb Running Injuries by Gender, Anatomical Location and Specific Pathology: A Systematic Review.

Running is associated with a higher risk of overuse injury than other forms of aerobic exercise such as walking, swimming and cycling. An accurate description of the proportion of running injuries per anatomical location and where possible, per specific pathology, for both genders is required. The aim of this review was to determine the proportion of lower limb running injuries by anatomical location and by specific pathology in male and female runners (≥800m - ≤ marathon). The preferred reporting items for systematic reviews and meta-analyses guidelines were followed for this review. A literature search was performed with no restriction on publication year in Web of Science, Scopus, Sport-Discus, PubMed, and CINAHL up to July 2017. Retrospective, cross-sectional, prospective and randomised-controlled studies which surveyed injury data in runners were included. 36 studies were included to report the overall proportion of injury per anatomical location. The overall proportion of injury by specific pathology was reported from 11 studies. The knee (28%), ankle-foot (26%) and shank (16%) accounted for the highest proportion of injury in male and female runners, although the proportion of knee injury was greater in women (40% vs. 31%). Relative to women, men had a greater proportion of ankle-foot (26% vs. 19%) and shank (21% vs. 16%) injuries. Patellofemoral pain syndrome (PFPS; 17%), Achilles tendinopathy (AT; 10%) and medial tibial stress syndrome (MTS; 8%) accounted for the highest proportion of specific pathologies recorded overall. There was insufficient data to sub-divide specific pathology between genders. The predominate injury in female runners is to the knee. Male runners have a more even distribution of injury between the knee, shank and ankle-foot complex. There are several methodological issues, which limit the interpretation of epidemiological data in running injury.

Incidence, Diagnosis, and Management of Injury in Sport Climbing and Bouldering: A Critical Review.

Competition climbing will debut as an Olympic sport at the 2020 summer games in Tokyo. The aim of this article is to critically review research on the incidence of injury in sport climbing and bouldering. The pathophysiology and clinical presentation of finger and shoulder injuries is discussed. A semisystematic approach in reviewing literature on incidence was applied. Articles were identified after searches of the following electronic databases: Discover, Academic Search Complete (EBSCO), PubMed, Embase, SPORTDiscus, and ScienceDirect. Despite methodological shortcomings of the included studies, we estimated the mean ± SD of the incidence rate of injury in sport climbing and bouldering from the eight studies to be 2.71 ± 4.49/1000 h. Differential diagnosis and the clinical management of finger and shoulder injuries in climbers are challenging. An updated diagnostic and therapeutic algorithm for the clinical management of finger injuries in climbers is presented.

Changing the size of a mirror-reflected hand moderates the experience of embodiment but not proprioceptive drift: a repeated measures study on healthy human participants.

Mirror visual feedback is used for reducing pain and visually distorting the size of the reflection may improve efficacy. The findings of studies investigating size distortion are inconsistent. The influence of the size of the reflected hand on embodiment of the mirror reflection is not known. The aim of this study was to compare the effect of magnifying and minifying mirror reflections of the hand on embodiment measured using an eight-item questionnaire and on proprioceptive drift. During the experiment, participants (n = 45) placed their right hand behind a mirror and their left hand in front of a mirror. Participants watched a normal-sized, a magnified and a minified reflection of the left hand while performing synchronised finger movements for 3 min (adaptive phase). Measurements of embodiment were taken before (pre) and after (post) synchronous movements of the fingers of both hands (embodiment adaptive phase). Results revealed larger proprioceptive drift post-adaptive phase (p = 0.001). Participants agreed more strongly with questionnaire items associated with location, ownership and agency of the reflection of the hand post-adaptive phase (p < 0.001) and when looking at the normal-sized reflection (p < 0.001). In conclusion, irrespective of size, watching a reflection of the hand while performing synchronised movements enhances the embodiment of the reflection of the hand. Magnifying and minifying the reflection of the hand has little effect on proprioceptive drift, but it weakens the subjective embodiment experience. Such factors need to be taken into account in future studies using this technique, particularly when assessing mirror visual feedback for pain management.

Transcutaneous electrical nerve stimulation (TENS) for fibromyalgia in adults.

BACKGROUND: Fibromyalgia is characterised by persistent, widespread pain; sleep problems; and fatigue. Transcutaneous electrical nerve stimulation (TENS) is the delivery of pulsed electrical currents across the intact surface of the skin to stimulate peripheral nerves and is used extensively to manage painful conditions. TENS is inexpensive, safe, and can be self-administered. TENS reduces pain during movement in some people so it may be a useful adjunct to assist participation in exercise and activities of daily living. To date, there has been only one systematic review in 2012 which included TENS, amongst other treatments, for fibromyalgia, and the authors concluded that TENS was not effective. OBJECTIVES: To assess the analgesic efficacy and adverse events of TENS alone or added to usual care (including exercise) compared with placebo (sham) TENS; no treatment; exercise alone; or other treatment including medication, electroacupuncture, warmth therapy, or hydrotherapy for fibromyalgia in adults. SEARCH METHODS: We searched the following electronic databases up to 18 January 2017: CENTRAL (CRSO); MEDLINE (Ovid); Embase (Ovid); CINAHL (EBSCO); PsycINFO (Ovid); LILACS; PEDRO; Web of Science (ISI); AMED (Ovid); and SPORTDiscus (EBSCO). We also searched three trial registries. There were no language restrictions. SELECTION CRITERIA: We included randomised controlled trials (RCTs) or quasi-randomised trials of TENS treatment for pain associated with fibromyalgia in adults. We included cross-over and parallel-group trial designs. We included studies that evaluated TENS administered using non-invasive techniques at intensities that produced perceptible TENS sensations during stimulation at either the site of pain or over nerve bundles proximal (or near) to the site of pain. We included TENS administered as a sole treatment or TENS in combination with other treatments, and TENS given as a single treatment or as a course of treatments. DATA COLLECTION AND ANALYSIS: Two review authors independently determined study eligibility by assessing each record and reaching agreement by discussion. A third review author acted as arbiter. We did not anonymise the records of studies before assessment. Two review authors independently extracted data and assessed risk of bias of included studies before entering information into a 'Characteristics of included studies' table. Primary outcomes were participant-reported pain relief from baseline of 30% or greater or 50% or greater, and Patient Global Impression of Change (PGIC). We assessed the evidence using GRADE and added 'Summary of findings' tables. MAIN RESULTS: We included eight studies (seven RCTs, one quasi-RCT, 315 adults (299 women), aged 18 to 75 years): six used a parallel-group design and two used a cross-over design. Sample sizes of intervention arms were five to 43 participants.Two studies, one of which was a cross-over design, compared TENS with placebo TENS (82 participants), one study compared TENS with no treatment (43 participants), and four studies compared TENS with other treatments (medication (two studies, 74 participants), electroacupuncture (one study, 44 participants), superficial warmth (one cross-over study, 32 participants), and hydrotherapy (one study, 10 participants)). Two studies compared TENS plus exercise with exercise alone (98 participants, 49 per treatment arm). None of the studies measured participant-reported pain relief of 50% or greater or PGIC. Overall, the studies were at unclear or high risk of bias, and in particular all were at high risk of bias for sample size.Only one study (14 participants) measured the primary outcome participant-reported pain relief of 30% or greater. Thirty percent achieved 30% or greater reduction in pain with TENS and exercise compared with 13% with exercise alone. One study found 10/28 participants reported pain relief of 25% or greater with TENS compared with 10/24 participants using superficial warmth (42 °C). We judged that statistical pooling was not possible because there were insufficient data and outcomes were not homogeneous.There were no data for the primary outcomes participant-reported pain relief from baseline of 50% or greater and PGIC.There was a paucity of data for secondary outcomes. One pilot cross-over study of 43 participants found that the mean (95% confidence intervals (CI)) decrease in pain intensity on movement (100-mm visual analogue scale (VAS)) during one 30-minute treatment was 11.1 mm (95% CI 5.9 to 16.3) for TENS and 2.3 mm (95% CI 2.4 to 7.7) for placebo TENS. There were no significant differences between TENS and placebo for pain at rest. One parallel group study of 39 participants found that mean ± standard deviation (SD) pain intensity (100-mm VAS) decreased from 85 ± 20 mm at baseline to 43 ± 20 mm after one week of dual-site TENS; decreased from 85 ± 10 mm at baseline to 60 ± 10 mm after single-site TENS; and decreased from 82 ± 20 mm at baseline to 80 ± 20 mm after one week of placebo TENS. The authors of seven studies concluded that TENS relieved pain but the findings of single small studies are unlikely to be correct.One study found clinically important improvements in Fibromyalgia Impact Questionnaire (FIQ) subscales for work performance, fatigue, stiffness, anxiety, and depression for TENS with exercise compared with exercise alone. One study found no additional improvements in FIQ scores when TENS was added to the first three weeks of a 12-week supervised exercise programme.No serious adverse events were reported in any of the studies although there were reports of TENS causing minor discomfort in a total of 3 participants.The quality of evidence was very low. We downgraded the GRADE rating mostly due to a lack of data; therefore, we have little confidence in the effect estimates where available. AUTHORS' CONCLUSIONS: There was insufficient high-quality evidence to support or refute the use of TENS for fibromyalgia. We found a small number of inadequately powered studies with incomplete reporting of methodologies and treatment interventions.

Positive surgical margins and biochemical recurrence following minimally-invasive radical prostatectomy - An analysis of outcomes from a UK tertiary referral centre.

BACKGROUND: Positive surgical margins are a strong prognostic marker of disease outcome following radical prostatectomy, though prior evidence is largely from a PSA-screened population. We therefore aim to evaluate the biochemical recurrence in men with positive surgical margins (PSM) after minimally-invasive radical prostatectomy (MIRP) in a UK tertiary centre. METHODS: Retrospective study of men undergoing laparoscopic or robotic-assisted radical prostatectomy between 2002 and 2014. Men with positive surgical margins (PSM) were identified and their biochemical recurrence (BCR) rate compared with men without PSM. The primary outcome measures were BCR rates and time to BCR. Cox regression was used to estimate adjusted hazard ratios for biochemical recurrence rate (BCR), accounting for potential confounders. RESULTS: Five hundred ninety-two men were included for analysis. Pre-operative D'Amico risk stratification showed 37.5%, 53.3% and 9.3% of patients in the low, intermediate and high-risk groups, respectively. On final pathological analysis, the proportion of patients with local staging pT2, pT3a and pT3b was 68.8%, 25.2% and 6.1% respectively. Overall positive margin rate was 30.6%. On multivariate analysis, the only pre-operative factor associated with PSM was age >65years. Patients with PSM were more likely to have higher tumour volume and more advanced pathological local stage. The BCR rate was 10.7% in margin-positive patients and 5.1% in margin-negative patients, at median 4.4-year follow-up. Upon multivariate analysis, high pre-operative PSA and high Gleason group were the only significant predictors of BCR (P<0.05). CONCLUSIONS: In comparison to patients with negative surgical margins, those with PSM do not translate into worse medium-term oncological outcomes in the majority of cases amongst our cohort. We found that high pre-operative PSA and high Gleason group were the only significant predictors of BCR.

Psychometric Properties of an Arabic Pain Anxiety Symptoms Scale-20 (PASS-20) in Healthy Volunteers and Patients Attending a Physiotherapy Clinic.

PURPOSE: The aim of this study was to cross-culturally adapt the PASS-20 questionnaire for use in Libya. METHODS: Participants were 71 patients (42 women) attending the physiotherapy clinic, Ibn Sina Hospital, Sirt, Libya for management of persistent pain and 137 healthy unpaid undergraduate students (52 women) from the University of Sirt, Libya. The English PASS-20 was translated into Arabic. Patients completed the Arabic PASS-20 and the Arabic Pain Rating Scales on two occasions separated by a 14-day interval. Healthy participants completed the Arabic PASS-20 on one occasion. RESULTS: The internal consistency (ICC) for pain patient and healthy participant samples yielded a good reliability for the total score, cognitive anxiety, fear of pain, and physiological anxiety. The test-retest reliability of the Arabic PASS-20 score showed high reliability for the total score (ICC = 0.93, p < 0.001), escape/avoidance (ICC = 0.93, p < 0.001), fear of pain (ICC = 0.94, p < 0.001), and physiological anxiety subscales (ICC = 0.96, p < 0.001) and good reliability for the cognitive anxiety (ICC = 0.85, p < 0.001). Inspection of the Promax rotation showed that each factor comprised of five items were consistent with the theoretical constructs of the original PASS-20 subscales. CONCLUSION: The Arabic PASS-20 retained internal consistency and reliability with the original English version and can be used to measure pain anxiety symptoms in both pain and healthy individual samples in Libya.