International, multi-disciplinary, cross-section study of pain knowledge and attitudes in nursing, midwifery and allied health professions students.

BACKGROUND: Persistent pain is a highly prevalent, global cause of disability. Research suggests that many healthcare professionals are not well equipped to manage pain, and this may be attributable at least in part to undergraduate education. The primary aim of this study was to quantify and compare first and final year nursing, midwifery and allied health professional (NMAHP) students' pain related knowledge and attitudes. The secondary aim was to explore what factors influence students' pain related knowledge and attitudes. METHODS: In this cross-sectional study, 1154 first and final year healthcare students, from 12 universities in five different countries completed the Revised Neurophysiology of Pain Quiz (RNPQ) [knowledge] and the Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS) [attitudes]. RESULTS: Physiotherapy was the only student group with statistically and clinically improved pain related knowledge [mean difference, 95% CI] (3.4, 3.0 to 3.9, p = 0.01) and attitudes (-17.2, -19.2 to 15.2, p = 0.01) between first and final year. Pain education teaching varied considerably from course to course (0 to 40 h), with greater levels of pain related knowledge and attitudes associated with higher volumes of pain specific teaching. CONCLUSIONS: There was little difference in pain knowledge and attitudes between all first and final year NMAHP students other than physiotherapy. This suggests that for most NMAHP disciplines, undergraduate teaching has little or no impact on students' understanding of pain. There is an urgent need to enhance pain education provision at the undergraduate level in NMAHPs. TRIAL REGISTRATION: The study protocol was prospectively registered at ClinicalTrials.Gov NCT03522857 .

A randomized controlled trial investigating effects of an individualized pedometer driven walking program on chronic low back pain.

BACKGROUND: Walking is an easily prescribed physical activity for people with low back pain (LBP). However, the evidence for its effectiveness to improve pain and disability levels for people with chronic low back pain (CLBP) within a community setting has not been evaluated. This study evaluates the effectiveness of a clinician guided, pedometer-driven, walking intervention for increasing physical activity and improving clinical outcomes compared to education and advice. METHODS: Randomized controlled trial recruiting N = 174 adults with CLBP. Participants were randomly allocated into either a standardized care group (SG) or pedometer based walking group (WG) using minimization allocation with a 2:1 ratio to the WG. Prior to randomization all participants were given a standard package of education and advice regarding self-management and the benefits of staying active. Following randomization the WG undertook a physiotherapist guided pedometer-driven walking program for 12 weeks. This was individually tailored by weekly negotiation of daily step targets. Main outcome was the Oswestry Disability Index (ODI) recorded at baseline, 12 weeks, 6 and 12 months. Other outcomes included, numeric pain rating, International Physical Activity Questionnaire (IPAQ), Fear-Avoidance Beliefs Questionnaire (FABQ), Back Beliefs questionnaire (BBQ), Physical Activity Self-efficacy Scale, and EQ-5D-5L quality of life estimate. RESULTS: N = 138 (79%) participants completed all outcome measures at 12 weeks reducing to N = 96 (55%) at 12 months. Both observed and intention to treat analysis did not show any statistically significant difference in ODI change score between the WG and the SG at all post-intervention time points. There were also no significant between group differences for change scores in all secondary outcome measures. Post hoc sensitivity analyses revealed moderately disabled participants (baseline ODI ≥ 21.0) demonstrated a greater reduction in mean ODI scores at 12 months in the WG compared to SG, while WG participants with a daily baseline step count < 7500 steps demonstrated a greater reduction in mean ODI scores at 12 weeks. CONCLUSIONS: Overall, we found no significant difference in change of levels of (ODI) disability between the SG and WG following the walking intervention. However, ODI responses to a walking program for those with moderate levels of baseline disability and those with low baseline step count offer a potential future focus for continued research into the benefit of walking as a management strategy for chronic LBP. TRIAL REGISTRATION: United States National Institutes of Health Clinical Trails registry (http://ClinicalTrials.gov/) No. NCT02284958 (27/10/2014).

A loaded self-managed exercise programme for patellofemoral pain: a mixed methods feasibility study.

BACKGROUND: A novel loaded self-managed exercise programme that includes pain education and self-management strategies may result in better outcomes for people with patellofemoral pain (PFP). However, establishing program feasibility is an essential first step before testing efficacy. The purpose of this study was to evaluate the feasibility and acceptability of conducting a definitive RCT which will evaluate the clinical and cost-effectiveness of a loaded self-managed exercise programme for people with PFP compared with usual physiotherapy. METHODS: In a mixed methods, pragmatic, randomised controlled feasibility study, 60 participants with PFP (57% female; mean age 29 years) were recruited from a physiotherapy clinic within a large UK teaching hospital. They were randomly allocated to receive either a loaded self-managed exercise programme (n = 30) or usual physiotherapy (n = 30). Feasibility indicators of process, resources, and management were collected through follow-up of standardised questionnaires six months after recruitment and semi-structured interviews with 20 participants and physiotherapists. RESULTS: Recruitment rate was 5 participants per month; consent rate was 99%; adherence to intervention appointments was 87%; completeness of questionnaire data was 100%; and adherence to intervention delivery was 95%. Three exercise diaries were returned at six months (5%). At six months, 25 questionnaire booklets were returned (9 in the loaded self-managed group, 16 in the usual physiotherapy group), with a total retention rate of 42%. At six months, 56% (5/9) of respondents in the loaded self-managed group and 56% (9/16) in the usual physiotherapy group were classified as 'recovered'. Both groups demonstrated improvements in average pain (VAS), kinesiophobia, pain catastrophizing, general self-efficacy and EQ-5D-5 L from baseline to six months. CONCLUSION: The results of this feasibility study confirm that it is feasible and acceptable to deliver a loaded self-managed exercise programme to adults with PFP in an NHS physiotherapy outpatient setting. However, between group differences in lost to follow up and poor exercise diary completion mean we are uncertain on some feasibility aspects. These methodological issues need addressing prior to conducting a definitive RCT. TRIAL REGISTRATION: ISRCTN 35272486 . Registered 19th December 2016.

The effectiveness of manual therapy in treating cervicogenic dizziness: a systematic review.

[Purpose] This review provides an evaluation of the evidence for the effectiveness of using manual therapy to treat cervicogenic dizziness. [Subjects and Methods] The literature was systematically searched on the May 2, 2016 using the following online databases: Medline, EMBASE, CINAHL and PEDro. This review included randomised controlled trials and compared the efficacy of manual therapy for the treatment of cervicogenic dizziness, compared to other types of intervention. This study measured changes based on dizziness intensity and frequency. [Results] The primary search found 30 articles, but only four articles met the inclusion criteria. Assessment of methodological quality was performed by two researchers using the PEDro scale. The level of evidence was determined using a recognised grading scale. Three out of the four articles were deemed to have high methodological quality, while the fourth was rated as moderate quality. The attributed level of evidence was moderate (level 2). [Conclusion] Manual therapy is potentially effective for managing cervicogenic dizziness. However, due to the heterogeneity of the results and techniques and the low number of studies, further research is recommended to provide conclusive evidence.

Current management strategies for patellofemoral pain: an online survey of 99 practising UK physiotherapists.

BACKGROUND: Patellofemoral pain (PFP) is considered one of the commonest forms of knee pain. This study aimed to identify how physiotherapists in the United Kingdom (UK) currently manage patellofemoral pain (PFP), particularly in relation to exercise prescription, and response to pain. METHODS: An anonymous survey was designed with reference to previous surveys and recent systematic reviews. Practising UK physiotherapists who treat patients with PFP were invited to take part via an invitation email sent through professional networks, the 'interactive Chartered Society of Physiotherapy (iCSP)' message board, and social media (Twitter). Descriptive statistics were used to analyse the data. RESULTS: A total of 99 surveys were completed. Responders reported a wide range of management strategies, including a broad selection of type and dose of exercise prescription. The five most common management strategies chosen were: closed chain strengthening exercises (98%); education and advice (96%); open chain strengthening exercises (76%); taping (70%) and stretches (65%). Physiotherapists with a special interest in treating PFP were statistically more likely to manage patients with orthotics (P = 0.02) and bracing (P = 0.01) compared to physiotherapists without a special interest. Approximately 55% would not prescribe an exercise if it was painful. Thirty-one percent of physiotherapists would advise patients not to continue with leisure and/or sporting activity if they experienced any pain. CONCLUSION: Current UK practice in the management strategies of PFP is variable. Further high quality research on which to inform physiotherapy practice is warranted for this troublesome musculoskeletal condition.

Should exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysis.

BACKGROUND: Chronic musculoskeletal disorders are a prevalent and costly global health issue. A new form of exercise therapy focused on loading and resistance programmes that temporarily aggravates a patient's pain has been proposed. The object of this review was to compare the effect of exercises where pain is allowed/encouraged compared with non-painful exercises on pain, function or disability in patients with chronic musculoskeletal pain within randomised controlled trials. METHODS: Two authors independently selected studies and appraised risk of bias. Methodological quality was evaluated using the Cochrane risk of bias tool, and the Grading of Recommendations Assessment system was used to evaluate the quality of evidence. RESULTS: The literature search identified 9081 potentially eligible studies. Nine papers (from seven trials) with 385 participants met the inclusion criteria. There was short- term significant difference in pain, with moderate quality evidence for a small effect size of -0.27 (-0.54 to -0.05) in favour of painful exercises. For pain in the medium and long term, and function and disability in the short, medium and long term, there was no significant difference. CONCLUSION: Protocols using painful exercises offer a small but significant benefit over pain-free exercises in the short term, with moderate quality of evidence. In the medium and long term there is no clear superiority of one treatment over another. Pain during therapeutic exercise for chronic musculoskeletal pain need not be a barrier to successful outcomes. Further research is warranted to fully evaluate the effectiveness of loading and resistance programmes into pain for chronic musculoskeletal disorders. PROSPERO REGISTRATION: CRD42016038882.

Pain and Physical Functioning in Neuropathic Pain: A Systematic Review of Psychometric Properties of Various Outcome Measures.

INTRODUCTION: A range of outcome measures across various domains are used to evaluate change following an intervention in clinical trials on chronic neuropathic pain (NeP). However, to capture a real change in the variable of interest, the psychometric properties of a particular measure should demonstrate appropriate methodological quality. Various outcome measures in the domains of pain and physical functioning have been used in the literature for NeP, for which individual properties (eg, reliability/validity) have been reported. To date, there is no definitive synthesis of evidence on the psychometric properties of those outcome measures; thus, the aim of this systematic review was to evaluate the methodological quality [COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) guidelines] of studies that evaluated psychometric properties of pain and physical functioning outcome measures used for NeP. METHODS: Specific MeSH/keywords related to 3 areas (pain and/or physical functioning, psychometric properties, and NeP) were used to retrieve relevant studies (English language) in key electronic databases (MEDLINE (Ovid), CINAHL (EBSCO), Scopus, AMED, and Web of Science) from database inception-July 2012. Articles retrieval/screening and quality analysis (COSMIN) were carried out by 2 independent reviewers. RESULTS: Twenty-four pain and thirty-seven physical functioning outcome measures were identified, varying in methodological quality from poor-excellent. CONCLUSION: Although a variety of pain and physical functioning outcome measures have been reported in the literature, few have demonstrate methodologically strong psychometric properties. Thus, future research is required to further investigate the psychometric properties of existing pain and physical functioning outcome measures used for clinical and research purposes.

A new gustometer for taste testing in rodents.

In recent years, to circumvent the interpretive limitations associated with intake tests commonly used to assess taste function in rodents, investigators have developed devices called gustometers to deliver small volumes of taste samples and measure immediate responses, thereby increasing confidence that the behavior of the animal is under orosensory control. Most of these gustometers can be used to measure unconditioned licking behavior to stimuli presented for short durations and/or can be used to train the animal to respond to various fluid stimuli differentially so as to obtain a reward and/or avoid punishment. Psychometric sensitivity and discrimination functions can thus be derived. Here, we describe a new gustometer design, successfully used in behavioral experiments, that was guided by our experience with an older version used for over 2 decades. The new computer-controlled gustometer features no dead space in stimulus delivery lines, effective cleaning of the licking substrate, and the ability to measure licking without passing electrical current through the animal. The parts and dimensions are detailed, and the benefits and limitations of certain design features are discussed. Schematics for key circuits are provided as supplemental information. Accordingly, it should be possible to fabricate this device in a fashion customized for one's needs.

Investigating the effect of a 3-month workplace-based pedometer-driven walking programme on health-related quality of life in meat processing workers: a feasibility study within a randomized controlled trial.

BACKGROUND: In New Zealand, meat processing populations face many health problems as a result of the nature of work in meat processing industries. The primary aim of this study was to examine the feasibility of using a pedometer-based intervention to increase physical activity and improve health-related outcomes in a population of meat processing workers. METHODS: A single-blinded randomized controlled trial (RCT) was conducted. A convenience sample of meat workers (n = 58; mean age 41.0 years; range: 18-65) participated in the trial. Participants were randomly allocated into two groups. Intervention participants (n = 29) utilized a pedometer to self monitor their activity, whilst undertaking a brief intervention, and educational material. Control participants (n = 29) received educational material only. The primary outcomes of ambulatory activity, and health-related quality of life, were evaluated at baseline, immediately following the 12-week intervention and three months post-intervention. RESULTS: Fifty three participants completed the program (91.3% adherence). Adherence with the intervention group was high, 93% (n = 27/29), and this group increased their mean daily step count from 5993 to 9792 steps per day, while the control group steps changed from 5788 to 6551 steps per day from baseline. This increase in step counts remained significant within the intervention group p < 0.005; at three months post-intervention representing a 59% increase over baseline scores. There were significant group changes with large effect sizes for step count change (d = 1.94) and self-reported physical activity (p < 0.005; d = 2.59) at 12 weeks intervention. Further, results showed non-significant between-group differences in physical component (PCS) and mental component (MCS) scores (PCS: p = 0.44; MGD = 0.99, 95% CI, -1.6 to 3.6; ES = 0.14, and MCS: p = 0.90, MGD = 0.15; 95% CI, -2.3 to 2.6, ES = 0.022) at 12 weeks intervention. CONCLUSIONS: This research provides important information for a larger (RCT) in the future: results demonstrated that a pedometer-driven walking intervention in combination with goal setting, and self-monitoring supported by weekly e-mails are feasible and potentially effective in increasing step count within the workplace setting over the short term. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613000087752.

Walking away from back pain: one step at a time - a community-based randomised controlled trial.

BACKGROUND: Low back pain is highly prevalent and a significant public health burden in Western society. Feasibility studies suggest personalised pedometer-driven walking is an acceptable and effective motivating tool in the management of chronic low back pain (CLBP ≥ 12 weeks). The proposed study will investigate pedometer-driven walking as a low cost, easily accessible, and sustainable means of physical activity to improve disability and clinical outcomes for people with CLBP in Saskatchewan, Canada. METHODS/DESIGN: A fully-powered single-blinded randomised controlled trial will compare back care advice and education with back care advice and education followed by a 12-week pedometer-driven walking programme in adults with CLBP. Adults with self-reported CLBP will be recruited from the community and screened for elibility. Two-hundred participants will be randomly allocated to one of two intervention groups. All participants will receive a single back care advice and education session with a physiotherapist. Participants in the walking group will also receive a physiotherapist-facilitated pedometer based walking programme. The physiotherapist will facilitate the participant to monitor and progress the walking programme, by phone, on a weekly basis over 10 weeks following two face-to-face sessions. Outcome measures of self-reported disability, physical activity, participants' low back pain beliefs/perceptions, quality of life and direct/indirect cost estimates will be gathered at baseline, three months, six months, and 12 months by a different physiotherapist blinded to group allocation. Following intervention, focus groups will be used to explore participants' thoughts and experiences of pedometer-driven walking as a management tool for CLBP. DISCUSSION: This paper describes the design of a community-based RCT to determine the effectiveness of a pedometer-driven walking programme in the management of CLBP. TRIAL REGISTRATION: United States National Institutes of Health Clinical Trails registry (http://ClinicalTrials.gov/) No. NCT02284958 . Registered on 27(th) October 2014).

A systematic review of studies using pedometers as an intervention for musculoskeletal diseases.

BACKGROUND: Physical activity (PA) plays an important role in the prevention and management of a number of chronic conditions. AIM: to investigate the evidence for effectiveness of pedometer-driven walking programs to promote physical activity among patients with musculoskeletal disorders (MSDs). METHOD: A comprehensive systematic review was performed using 11 electronic databases up to 20 February 2014. Keywords and MeSH terms included "musculoskeletal disorders", "walking", and "pedometer". Randomized controlled trials, published in English, that examined the effects of a pedometer-based walking intervention to increase physical activity levels and improve physical function and pain in patients with musculoskeletal disorders were included. RESULT: Of the 1996 articles retrieved, seven studies ranging in date of publication from 1998 to 2013 met the inclusion criteria, allowing data extraction on 484 participants with an age range of 40 to 82 years. Interventions lasted from 4 weeks to 12 months and the results across studies showed significant increases in step count (p < 0.05) following the intervention. Across these studies, there was a mean increase in PA of 1950 steps per day relative to baseline. Four studies reported improved scores for pain and/or physical function at the intervention completion point relative to controls. CONCLUSION: This study provides strong evidence for the effectiveness of pedometer walking interventions in increasing PA levels for patients with MSDs. Our findings suggest that a combination of interventions is likely to be the most effective strategy to maximize health benefits in the short term. Further research should include larger sample sizes, and longer intervention durations are required to support the role of pedometer walking interventions as a long term intervention for management of musculoskeletal disorders.

Influence of central aspects of pain on self-management in people with chronic low back pain.

OBJECTIVE: This observational study investigated whether central aspects of pain are associated with self-management domains in individuals with chronic low back pain (CLBP) undertaking a pain management program. METHODS: Individuals with CLBP provided pain sensitivity and self-management data at baseline (n = 97) and 3-months (n = 87). Pressure pain detection threshold (PPT) at the forearm, temporal summation (TS) and conditioned pain modulation (CPM), Widespread Pain Index (WPI), and a Central Aspects of Pain factor (CAPf) were considered as central aspects of pain. Self-management was measured using the 8 domains of the Health Education Impact Questionnaire, as well as Pain Self Efficacy and Health Care Utilisation questionnaires. RESULTS: PPT, CPM, WPI and CAPf predicted worse performance in several self-management domains at 3-months (r = 0.21 to 0.54, p < 0.05 overall). In multivariable regression models (adjusted for baseline scores of self-management, depression, catastrophization, pain and fatigue) low PPT, high TS, and high CAPf at baseline predicted poorer self-management at 3 months (R2 =0.14 to 0.52, ß = -0.37 to 0.35, p < 0.05). CONCLUSIONS: Central aspects of pain are associated with impaired self-management, over and above effects of pain intensity, fatigue, depression and catastrophizing. PRACTICE IMPLICATIONS: Treatments that target central aspects of pain might help improve self-management in people with CLBP.

Barriers and facilitators to the delivery of a biopsychosocial education and exercise programme for patients with chronic low back pain in Ghana. A qualitative study.

PURPOSE: Low back pain management has evolved with researchers advocating for a biopsychosocial management model. The biopsychosocial management model has been predominantly applied in high-income countries and underexplored in low- and middle-income countries including Ghana. This study aimed to explore the potential barriers and facilitators to patients with chronic low back pain (CLBP) and physiotherapists engagement with a biopsychosocial intervention (exercise and patient education) as part of a feasibility study. MATERIAL AND METHODS: This was a qualitative study embedded within a mixed-methods, sequential, feasibility study, in Ghana, applying semi-structured interviews. Two categories of participants involved in this study were, two trained physiotherapists, and six patients with CLBP, sampled within the feasibility study. RESULTS: Regarding the barriers and facilitators to the delivery of the BPS intervention, five interlinked themes emerged from the thematic analysis. These were: structure and process of delivery; patients' expectations; patients' health beliefs, autonomy, and engagement; external influences and personal and professional characteristics of physiotherapists. CONCLUSION: The themes that emerged from this study demonstrated many positive facilitators based on participants' improved understanding of LBP and the clarity and purpose of the biopsychosocial intervention. The results therefore demonstrate a potential to deliver the biopsychosocial intervention in a Ghanaian context.

A biopsychosocial approach to managing chronic low back pain offers a promising alternative to patients and physiotherapists in Ghana.A biopsychosocial approach to managing chronic low back pain has the potential to improve physiotherapists' thoughts and attitudes, and have a positive influence on their professional development in Ghana.A biopsychosocial approach to managing chronic low back pain has the potential to reverse patients' maladaptive beliefs, improve their understanding of their condition, improve outcomes in Ghana.

Use of pedometer-driven walking to promote physical activity and improve health-related quality of life among meat processing workers: a feasibility trial.

BACKGROUND: Current evidence supports the use of pedometers as effective motivational tools to promote physical activity and improve health-related quality of life in the general population. The aims of this study are to examine whether a pedometer-driven walking programme can improve health-related quality of life, and increase ambulatory activity in a population of meat processing workers when compared to a control group receiving educational material alone. METHODS/DESIGN: A feasibility study employing a randomized controlled trial (RCT) design will collect data at three time points. A sample of up to 60 meat workers will be recruited and randomly assigned to either an intervention group N = 30 (12-week pedometer-driven walking program, brief intervention, and educational material), or control group N = 30 (educational material only). The primary outcomes of ambulatory activity, health-related quality of life, and functional capacity, will be evaluated at baseline, immediately following the 12-week intervention and then at three month post-intervention. DISCUSSION: This paper describes the design of a feasibility randomized controlled trial, which aims to assess the effectiveness of the introduction of a workplace pedometer-driven walking program compared to normal lifestyle advice in meat processing workers. TRIAL REGISTRATION NUMBER (ANZCTR): 12613000087752.

Does a patient's physical activity predict recovery from an episode of acute low back pain? A prospective cohort study.

BACKGROUND: Advice to remain active and normalisation of activity are commonly prescribed in the management of low back pain (LBP). However, no research has assessed whether objective measurements of physical activity predict outcome and recovery in acute low back pain. METHOD: The aims of this study were to assess the predictive relationship between activity and disability at 3 months in a sub-acute LBP population. This prospective cohort study recruited 101 consenting patients with sub-acute LBP (< 6 weeks) who completed the Roland Morris Disability Questionnaire (RMDQ), the Visual Analogue Scale, and resumption of full 'normal' activity question (Y/N), at baseline and 3 months. Physical activity was measured for 7 days at both baseline and at 3 months with an RT3 accelerometer and a recall questionnaire. RESULTS: Observed and self-reported measures of physical activity at baseline and change in activity from baseline to 3 months were not independent predictors of RMDQ (p > 0.05) or RMDQ change (p > 0.05) over 3 months. A self-report of a return to full 'normal' activities was significantly associated with greater RMDQ change score at 3 months (p < 0.001). Paired t-tests found no significant change in activity levels measured with the RT3 (p = 0.57) or the recall questionnaire (p = 0.38) from baseline to 3 months. CONCLUSIONS: These results question the predictive role of physical activity in LBP recovery, and the assumption that activity levels change as LBP symptoms resolve. The importance of a patient's perception of activity limitation in recovery from acute LBP was also highlighted. TRIAL REGISTRATION: Clinical Trial Registration Number, ACTRN12609000282280.

The lived experiences of musculoskeletal physiotherapists managing patient expectations for diagnostic imaging: A qualitative study using a phenomenological analysis.

OBJECTIVES: Unnecessary diagnostic imaging for musculoskeletal presentations is a pervasive phenomenon, placing a substantial weight on healthcare resources. Their overuse can lead to iatrogenic consequences associated with overdiagnosis and overtreatment. Factors which contribute to inappropriate imaging are multifactorial. Clinician-patient beliefs, behaviours, and expectations have been identified as central drivers. Physiotherapists play an important role in the utilisation of diagnostic imaging for musculoskeletal presentations throughout healthcare settings. This study aims to explore the lived experiences of physiotherapists managing patient expectations for diagnostic imaging. DESIGN: A qualitative study using an interpretative phenomenological analysis. Five participants were purposefully recruited and took part in semi-structured individual interviews. RESULTS: The central themes identified were expectations for diagnostic imaging, managing expectations, communicating imaging findings, imaging as a therapeutic tool, and risk and uncertainty. CONCLUSION: The findings from this study gives new insights into how musculoskeletal physiotherapists manage expectations for diagnostic imaging, the associated complexities, and the challenges encountered.

An observational study of centrally facilitated pain in individuals with chronic low back pain.

Introduction: Central pain facilitation can hinder recovery in people with chronic low back pain (CLBP). Objectives: The objective of this observational study was to investigate whether indices of centrally facilitated pain are associated with pain outcomes in a hospital-based cohort of individuals with CLBP undertaking a pain management programme. Methods: Participants provided self-report and pain sensitivity data at baseline (n = 97) and again 3 months (n = 87) after a cognitive behavioural therapy-based group intervention including physiotherapy. Indices of centrally facilitated pain were pressure pain detection threshold, temporal summation and conditioned pain modulation at the forearm, Widespread Pain Index (WPI) classified using a body manikin, and a Central Mechanisms Trait (CMT) factor derived from 8 self-reported characteristics of anxiety, depression, neuropathic pain, fatigue, cognitive dysfunction, pain distribution, catastrophizing, and sleep. Pain severity was a composite factor derived from Numerical Rating Scales. Cross-sectional and longitudinal regression models were adjusted for age and sex. Results: Baseline CMT and WPI each was associated with higher pain severity (CMT: r = 0.50, P < 0.001; WPI: r = 0.21, P = 0.04) at baseline and at 3 months (CMT: r = 0.38, P < 0.001; WPI: r = 0.24, P = 0.02). High baseline CMT remained significantly associated with pain at 3 months after additional adjustment for baseline pain (ß = 2.45, P = 0.04, R 2 = 0.25, P < 0.0001). Quantitative sensory testing indices of pain hypersensitivity were not significantly associated with pain outcomes at baseline or at 3 months. Conclusion: Central mechanisms beyond those captured by quantitative sensory testing are associated with poor CLBP outcome and might be targets for improved therapy.

ASSERT (Acute Sacral inSufficiEncy fractuRe augmenTation): randomised controlled, feasibility trial in older people.

OBJECTIVE: To determine the feasibility of designing and conducting a definitive trial to evaluate the effectiveness of sacral fracture fixation compared with non-surgical management among older people admitted with a lateral compression pelvic fragility fracture (PFF). DESIGN: Single-site, parallel, two-arm randomised controlled feasibility trial. SETTING: A UK tertiary centre hospital. PARTICIPANTS: Patients aged ≥70 years who were ambulating pre-injury requiring hospital admission (within 28 days of injury) with a type 1 lateral compression PFF. INTERVENTIONS: The intervention group received sacral fracture fixation (cement augmentation±screw fixation) within 7 days of randomisation. Routine preoperative and postoperative care followed each surgical intervention. The control group received usual care consisting of analgesia, and regular input from the medical and therapy team. PRIMARY AND SECONDARY OUTCOME MEASURES: The feasibility outcomes were the number of eligible patients, willingness to be randomised, adherence to allocated treatment, retention, data on the completeness and variability of the proposed definitive trial outcome measures, and reported adverse events. RESULTS: 241 patients were screened. 13 (5.4%) were deemed eligible to participate. Among the eligible participants, nine (69.2%) were willing to participate. Five participants were randomised to the intervention group and four to the control group. The clinicians involved were willing to allow their patients to be randomised and adhere to the allocated treatment. One participant in the intervention group and two participants in the control group received their allocated treatment. All participants were followed up until 12 weeks post-randomisation, and had an additional safety follow-up assessment at 12 months. Overall, the proportion of completeness of outcome measures was at least 75%. No adverse events were directly related to the trial. CONCLUSIONS: There were significant challenges in recruiting sufficient participants which will need to be addressed prior to a definitive trial. TRIAL REGISTRATION NUMBER: ISRCTN16719542.

The relationship between physical activity and low back pain outcomes: a systematic review of observational studies.

Although clinical guidelines advocate exercise and activity in the management of non-specific low back pain (NSLBP), the link between levels of physical activity and outcomes is unclear. This systematic review investigated the relationships between free living activity levels after onset of low back pain (LBP) and measures of pain, and disability in patients with NSLBP. Cohort and cross-sectional studies were located using OVID, CINAHL, Medline, AMED, Embase, Biomed, PubMed-National Library of Medicine, Proquest and Cochrane Databases, and hand searches of reference lists. Studies were included if a statistical relationship was investigated between measures of free living physical activity (PA) in subjects with LBP and LBP outcome measures. Twelve studies (seven cohort and five cross-sectional) were included. One prospective study reported a statistically significant relationship between increased leisure time activity and improved LBP outcomes, and one cross-sectional study found that lower levels of sporting activity were associated with higher levels of pain and disability. All other studies (n = 10) found no relationship between measures of activity levels and either pain or disability. Heterogeneity of study designs, particularly in terms of activity measurement, made comparisons between studies difficult. These data suggest that the activity levels of patients with NSLBP are neither associated with, nor predictive of, disability or pain levels. Validated activity measurement in prospective research is required to better evaluate the relationships between PA and LBP.