Kinetic chain revisited: consensus expert opinion on terminology, clinical reasoning, examination, and treatment in people with shoulder pain.

BACKGROUND: The purpose of this study was to reach consensus on the most appropriate terminology and issues related to clinical reasoning, examination, and treatment of the kinetic chain (KC) in people with shoulder pain among an international panel of experts. METHODS: A 3-round Delphi study that involved an international panel of experts with extensive clinical, teaching, and research experience in the study topic was conducted. A search equation of terms related to the KC in Web of Science and a manual search were used to find the experts. Participants were asked to rate items across 5 different domains (terminology, clinical reasoning, subjective examination, physical examination, and treatment) using a 5-point Likert-type scale. An Aiken coefficient of validity (V) ≥0.7 was considered indicative of group consensus. RESULTS: The participation rate was 30.2% (n = 16), whereas the retention rate was high throughout the 3 rounds (100%, 93.8%, and 100%). A total of 15 experts from different fields and countries completed the study. After the 3 rounds, consensus was reached on 102 items: 3 items were included in the "terminology" domain; 17 items, in the "rationale and clinical reasoning" domain; 11 items, in the "subjective examination" domain; 44 items, in the "physical examination" domain; and 27 items, in the "treatment" domain. Terminology was the domain with the highest level of agreement, with 2 items achieving an Aiken V of 0.93, whereas the domains of physical examination and treatment of the KC were the 2 areas with less consensus. Together with the terminology items, 1 item from the treatment domain and 2 items from the rationale and clinical reasoning domain reached the highest level of agreement (V = 0.93 and V = 0.92, respectively). CONCLUSION: This study defined a list of 102 items across 5 different domains (terminology, rationale and clinical reasoning, subjective examination, physical examination, and treatment) regarding the KC in people with shoulder pain. The term "KC" was preferred and a agreement on a definition of this concept was reached. Dysfunction of a segment in the chain (ie, weak link) was agreed to result in altered performance or injury to distal segments. Experts considered it important to assess and treat the KC in particular in throwing or overhead athletes and agreed that no one-size-fits-all approach exists when implementing shoulder KC exercises within the rehabilitation process. Further research is now required to determine the validity of the identified items.

Effects of Adding Motor Imagery to Early Physical Therapy in Patients with Knee Osteoarthritis who Had Received Total Knee Arthroplasty: A Randomized Clinical Trial.

OBJECTIVE: To investigate the effects of the inclusion of motor imagery (MI) principles into early physical therapy on pain, disability, pressure pain thresholds (PPTs), and range of motion in the early postsurgical phase after total knee arthroplasty (TKA). METHODS: A randomized clinical trial including patients with knee osteoarthritis who have received TKA was conducted. Participants were randomized to receive five treatment sessions of either physical therapy with or without MI principles in an early postsurgical phase after a TKA (five days after surgery). Pain intensity (visual analog scale [VAS], 0-100), pain-related disability (short-form Western Ontario McMaster Universities Osteoarthritis Index [WOMAC], 0-32), pressure pain thresholds (PPTs), and knee range of motion were assessed before and after five daily treatment sessions by an assessor blinded to the subject's condition. RESULTS: Twenty-four participants completed data collection and treatment. The adjusted analysis revealed significant group*time interactions for WOMAC (F = 17.29, P = 0.001, η2 = 0.48) and VAS (F = 14.56, P < 0.001, η2 = 0.45); patients receiving physiotherapy and MI principles experienced greater improvements in pain (Δ -28.0, 95% confidence interval [CI] = -43.0 to -13.0) and pain-related disability (Δ -6.0, 95% CI = -8.3 to -3.7) than those receiving physiotherapy alone. No significant group*time interactions for knee range of motion and PPTs were observed (all, P > 0.30). CONCLUSIONS: The application of MI to early physiotherapy was effective for improving pain and disability, but not range of motion or pressure pain sensitivity, in the early postsurgical phase after TKA in people with knee osteoarthritis.

How Much Is Needed? Comparison of the Effectiveness of Different Pain Education Dosages in Patients with Fibromyalgia.

OBJECTIVE: To assess the effect of different dosages of pain neuroscience education (PNE) programs on central nociceptive processing in patients with fibromyalgia. Second, to compare the effects of different dosages of PNE programs on numerical pain rating scale (NPRS), disability, and psychological variables. DESIGN: Single-blind randomized controlled trial. SETTING: Three fibromyalgia centers in Spain (Valencia, Alcorcón, Alcalá de Henares). SUBJECTS: Seventy-seven patients with fibromyalgia. METHODS: Participants were randomized to four groups of PNE: 1) high-dose PNE (N = 20), 2) low-concentrated dose PNE (N = 20), 3) diluted low-dose PNE (N = 20), and (4) control treatment (N = 17), conducted in two 30-50-minute sessions in groups of four to six participants. Conditioned pain modulation (CPM), temporal summation (TS), and pressure pain thresholds (PPTs) were assessed at baseline and at three-month follow-up. Secondary outcome measures were the Fibromyalgia Impact Questionnaire, Pain Catastrophizing Scale, and Pain Anxiety Symptoms Scale. RESULTS: There were significant between-group differences for NPRS in favor of the groups receiving high-dose PNE, with a large effect size at three-month follow-up (P < 0.01, η2p = 0.170), but there were no significant differences between groups for the remaining variables (P > 0.05). All groups improved for central nociceptive processing, psychological variables, disability, and pain intensity (NPRS). CONCLUSIONS: In patients with fibromyalgia, higher dosages of PNE produced a larger improvement in pain severity at three-month follow-up than other dosages of PNE and biomedical education. However, PNE was not superior to biomedical education in the central nociceptive processing, disability, or psychological variables in patients with fibromyalgia.

Pain neuroscience education and physical exercise for patients with chronic spinal pain in primary healthcare: a randomised trial protocol.

BACKGROUND: Chronic musculoskeletal pain affects more than 20% of the population, and the prevalence is increasing, causing suffering, loss of quality of life, disability, and an enormous expenditure on healthcare resources. The most common location for chronic pain is the spine. Many of the treatments used are mainly passive (pharmacological and invasive) and poor outcomes. The treatments currently applied in the public health system do not comply with the recommendations of the main clinical practice guidelines, which suggest the use of educational measures and physical exercise as the first-line treatment. A protocol based on active coping strategies is described, which will be evaluated through a clinical trial and which could facilitate the transfer of the recommendations of the clinical practice guidelines to a primary care setting. METHODS: Randomised and multicentre clinical trials, which will be carried out in 10 Primary Care centres. The trial will compare the effect of a Pain Neuroscience Education program (six sessions, 10 h) and group physical exercise (18 sessions program carried out in six weeks, 18 h), with usual care physiotherapy treatment. Group physical exercise incorporates dual tasks, gaming, and reinforcement of contents of the educational program. The aim is to assess the effect of the intervention on quality of life, as well as on pain, disability, catastrophism, kinesiophobia, central sensitisation, and drug use. The outcome variables will be measured at the beginning of the intervention, after the intervention (week 11), at six months, and a year. DISCUSSION: Therapeutic interventions based on active coping strategies are essential for the treatment of chronic pain and the sustainability of the Public Health System. Demonstrating whether group interventions have an effect size is essential for optimising resources in such a prevalent problem. TRIAL REGISTRATION: NCT03654235 "Retrospectively registered" 31 August 2018.

The Influence of Treatment Expectations on Clinical Outcomes and Cortisol Levels in Patients With Chronic Neck Pain: An Experimental Study.

BACKGROUND: The role of contextual factors like pre-existing treatment expectations has been established. However, the effect of verbally delivered treatment expectations in patient-therapist communication has not been considered, nor has the role of cortisol changes within the placebo/nocebo response in people with chronic neck pain. OBJECTIVE: To examine the effect of verbally delivered treatment expectations on clinical outcomes in physical therapy practice and to determine if changes in cortisol levels are associated with changes in neck pain and disability. METHODS: Eighty-three patients with chronic neck pain were randomly allocated to 3 different verbally delivered expectations (positive, negative, neutral) during physical therapy interventions. MAIN OUTCOME MEASURES: salivary cortisol, pain and disability, and cervical range of motion. RESULTS: Pain significantly improved in the positive (P < 0.001) and neutral (P < 0.001) expectations groups. For salivary cortisol levels, a significant increase was observed in response to treatment in the neutral (P = 0.045) and negative (P < 0.001) expectations groups. No significant correlations were found between changes in salivary cortisol levels and the change in pain in the neutral and negative expectations groups. CONCLUSIONS: Physical therapists treating people with chronic neck pain should be attentive when communicating the expected treatment effects to their patients. Whereas verbally delivered positive or neutral expectations may be beneficial for pain-related measures, giving negative expectations may result in a lack of a treatment response on pain. Cortisol levels increased in response to verbally delivered neutral and negative expectations, in the absence of a nocebo effect. This questions the presumed role of cortisol in the nocebo effect.

Pain Neurophysiology Education and Therapeutic Exercise for Patients With Chronic Low Back Pain: A Single-Blind Randomized Controlled Trial.

OBJECTIVE: To assess the effect of a pain neurophysiology education (PNE) program plus therapeutic exercise (TE) for patients with chronic low back pain (CLBP). DESIGN: Single-blind randomized controlled trial. SETTING: Private clinic and university. PARTICIPANTS: Patients with CLBP for ≥6 months (N=56). INTERVENTIONS: Participants were randomized to receive either a TE program consisting of motor control, stretching, and aerobic exercises (n=28) or the same TE program in addition to a PNE program (n=28), conducted in two 30- to 50-minute sessions in groups of 4 to 6 participants. MAIN OUTCOMES MEASURES: The primary outcome was pain intensity rated on the numerical pain rating scale which was completed immediately after treatment and at 1- and 3-month follow-up. Secondary outcome measures were pressure pain threshold, finger-to-floor distance, Roland-Morris Disability Questionnaire, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, and Patient Global Impression of Change. RESULTS: At 3-month follow-up, a large change in pain intensity (numerical pain rating scale: -2.2; -2.93 to -1.28; P<.001; d=1.37) was observed for the PNE plus TE group, and a moderate effect size was observed for the secondary outcome measures. CONCLUSIONS: Combining PNE with TE resulted in significantly better results for participants with CLBP, with a large effect size, compared with TE alone.

Which Portion of Physiotherapy Treatments' Effect Is Not Attributable to the Specific Effects in People With Musculoskeletal Pain? A Meta-Analysis of Randomized Placebo-Controlled Trials.

OBJECTIVE: We aimed to quantify the proportion not attributable to the specific effects (PCE) of physical therapy interventions for musculoskeletal pain. DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: We searched Ovid, MEDLINE, EMBASE, CINAHL, Scopus, PEDro, Cochrane Controlled Trials Registry, and SPORTDiscus databases from inception to April 2023. STUDY SELECTION CRITERIA: Randomized placebo-controlled trials evaluating the effect of physical therapy interventions on musculoskeletal pain. DATA SYNTHESIS: Risk of bias was evaluated using the Cochrane risk-of-bias tool for randomized trials (RoB 2). The proportion of physical therapy interventions effect that was not explained by the specific effect of the intervention was calculated, using the proportion not attributable to the specific effects (PCE) metric, and a quantitative summary of the data from the studies was conducted using the random-effects inverse-variance model (Hartung-Knapp-Sidik-Jonkman method). RESULTS: Sixty-eight studies were included in the systematic review (participants: n = 5238), and 54 placebo-controlled trials informed our meta-analysis (participants: n = 3793). Physical therapy interventions included soft tissue techniques, mobilization, manipulation, taping, exercise therapy, and dry needling. Placebo interventions included manual, nonmanual interventions, or both. The proportion not attributable to the specific effects of mobilization accounted for 88% of the immediate overall treatment effect for pain intensity (PCE = 0.88, 95% confidence interval [CI]: 0.57, 1.20). In exercise therapy, this proportion accounted for 46% of the overall treatment effect for pain intensity (PCE = 0.46, 95% CI: 0.41, 0.52). The PCE in manipulation excelled in short-term pain relief (PCE = 0.81, 95% CI: 0.62, 1.01) and in mobilization in long-term effects (PCE = 0.86, 95% CI: 0.76, 0.96). In taping, the PCE accounted for 64% of disability improvement (PCE = 0.64, 95% CI: 0.48, 0.80). CONCLUSION: The outcomes of physical therapy interventions for musculoskeletal pain were significantly influenced by factors not attributable to the specific effects of the interventions. Boosting these factors consciously to enhance therapeutic outcomes represents an ethical opportunity that could benefit patients. J Orthop Sports Phys Ther 2024;54(6):391-399. Epub 11 April 2024. doi:10.2519/jospt.2024.12126.

Assessing the use of the frequency, etiology, direction, and severity classification system for shoulder instability in physical therapy research - A scoping review.

OBJECTIVE: The aim of this study is to review the implementation of the Frequency, Etiology, Direction, and Severity (FEDS) classification for shoulder instability by the physical therapy scientific community since its publication in 2011. METHODS: A systematic search was conducted on January 10, 2024 in the MEDLINE, EMBASE, SPORTDiscus, Scopus, Web of Science, Cochrane, and SciELO databases, as well as Google Scholar. Studies investigating physical therapy interventions in people with shoulder instability, and reporting selection criteria for shoulder instability were considered eligible. A narrative synthesis was conducted. RESULTS: Twenty-six studies were included. None reported using the FEDS classification as eligibility criteria for shoulder instability. Only 42% of the studies provided data of all four criteria of the FEDS classification. The most reported criterion was direction (92%), followed by etiology (85%), severity (65%), and frequency (58%). The most common reported descriptor for profiling shoulder instability was "dislocation" (83.3%), followed by "first-time" (66.7%), "anterior" (62.5%), and "traumatic" (59.1%). Regarding other instability classifications, only one study (4%) used the Thomas & Matsen classification, and two (8%) the Stanmore classification. CONCLUSIONS: The FEDS classification system has not been embraced enough by the physical therapy scientific community since its publication in 2011.

Differences in biomechanical and metabolic factors between patients with frozen shoulder and asymptomatic individuals. A cross-sectional study.

BACKGROUND: the pathogenesis of frozen shoulder (FS) is thought to be one of inflammation and fibrosis possibly influenced by hyperglycemia. Biomechanical changes of the shoulder joint in terms of muscle strength, scapular kinematics and proprioception might occur in FS. OBJECTIVES: to compare muscle strength, scapular kinematics, proprioception, and blood glucose levels within patients with FS and to asymptomatic individuals. DESIGN: cross-sectional study. METHOD: Thirty-five patients with FS and 35 asymptomatic age and gender-matched individuals underwent physical assessment to determine muscle strength (abduction, external and internal rotation), scapular kinematics (both visually and with a plurimeter), proprioception (joint position sense), and blood glucose level. RESULTS: Patients with FS showed a decrease in muscle strength in their affected shoulder compared to both the unaffected shoulder and asymptomatic individuals. Significant differences were found between the affected and unaffected shoulder in the FS group and between groups (FS versus controls) in scapular upward rotation (plurimeter) at 30° and 60° abduction. No difference in scapular kinematics (visual observation), proprioception, and blood glucose levels was found neither between shoulders in the FS group nor between groups. CONCLUSION: A clinically relevant difference in muscle strength and increase in scapular upward rotation were found in the affected shoulder of patients with FS compared to their unaffected side and controls. However, no evidence of different levels of scapular kinematics (visual observation), proprioception, and blood glucose levels in the affected shoulder compared to the unaffected shoulder or controls is lacking.

Association between widespread pain and psychosocial factors in people with knee osteoarthritis: a cross-sectional study of patients from primary care in Denmark.

INTRODUCTION: The relationship between psychosocial factors and bodily pain in people with knee osteoarthritis (KOA) is unclear. PURPOSE: To examine whether widespread pain was associated with poorer self-efficacy, more anxiety, depression, and kinesiophobia in people with KOA. METHODS: This was a cross-sectional study based on data from Good Life with osteoArthritis in Denmark (GLA:D®). The association between widespread pain (multiple pain sites) and self-efficacy (Arthritis Self-Efficacy Scale), anxiety and depression (item from the EQ-5D-5 L), and kinesiophobia (yes/no) was examined using multiple linear tobit or logistic regression models. RESULTS: Among 19,323 participants, 10% had no widespread pain, 37% had 2 pain sites, 26% had 3-4 pain sites, and 27% had ≥5 pain sites. Widespread pain was associated with poorer self-efficacy (-0.9 to -8.3 points), and the association was stronger with increasing number of pain sites (p-value <.001). Significant increasing odds ratios (ORs) were observed for having anxiety or depression with 3-4 pain sites (OR 1.29, 95% CI 1.12; 1.49) and ≥5 pain sites (OR 1.80, 95% CI 1.56; 2.07). Having 2 and 3-4 pain sites were associated with lower odds of kinesiophobia compared to having no widespread pain. CONCLUSION: Widespread pain was associated with lower self-efficacy and more anxiety and depression but also lower kinesiophobia in people with KOA.

Pain neuroscience education for patients with chronic pain: A scoping review from teaching-learning strategies, educational level, and cultural perspective.

OBJECTIVE: (1) To identify the characteristics of PNE programs in terms of teaching-learning strategies, session modality, content delivery format, number of sessions, total minutes and instructional support material used in patients with chronic musculoskeletal pain, (2) to describe PNE adaptations for patients with different educational levels or cultural backgrounds, and (3) to describe the influence of the patient's educational level or cultural background on the effects of PNE. METHODS: The PRISMA guideline for scoping reviews was followed. Nine databases were systematically searched up to July 8, 2023. Articles that examined clinical or psychosocial variables in adults with chronic musculoskeletal pain who received PNE were included. RESULTS: Seventy-one articles were included. Studies found benefits of PNE through passive/active teaching-learning strategies with group/individual sessions. However, PNE programs presented great heterogeneity and adaptations to PNE were poorly reported. Most studies did not consider educational level and culture in the effects of PNE. CONCLUSIONS: Despite the large number of studies on PNE and increased interest in this intervention, the educational level and culture are poorly reported in the studies. PRACTICAL IMPLICATIONS: It is recommended to use passive and/or active teaching-learning strategies provided in individual and/or group formats considering the patient's educational level and culture.

Longitudinal Changes and Associations Between Quantitative Sensory Testing and Psychological Factors in Whiplash-Associated Disorders: A Systematic Review and Meta-Analyses-Based Data Synthesis.

Whiplash-associated disorders (WAD) represent a multifactorial condition often accompanied by altered nociceptive processing and psychological factors. This systematic review on acute and chronic WAD aimed to investigate the relationship between quantitative sensory testing (QST) and psychological factors and quantify whether their trajectories over time follow a similar pattern to disability levels. Eight databases were searched until October 2022. When 2 prospective studies examined the same QST or psychological variable, data synthesis was performed with random-effects meta-analysis by pooling within-group standardized mean differences from baseline to 3-, 6-, and 12-month follow-ups. From 5,754 studies, 49 comprising 3,825 WAD participants were eligible for the review and 14 for the data synthesis. Altered nociceptive processing in acute and chronic WAD, alongside worse scores on psychological factors, were identified. However, correlations between QST and psychological factors were heterogeneous and inconsistent. Furthermore, disability levels, some QST measures, and psychological factors followed general positive improvement over time, although there were differences in magnitude and temporal changes. These results may indicate that altered psychological factors and increased local pain sensitivity could play an important role in both acute and chronic WAD, although this does not exclude the potential influence of factors not explored in this review. PERSPECTIVE: Acute WAD show improvements in levels of disability and psychological factors before significant improvements in nociceptive processing are evident. Facilitated nociceptive processing might not be as important as psychological factors in chronic WAD-related disability, which indicates that chronic and acute WAD should not be considered the same entity although there are similarities. Nonetheless, pressure pain thresholds in the neck might be the most appropriate measure to monitor WAD progression.

Effectiveness of non-surgical management in rotator cuff calcific tendinopathy (the effect trial): protocol for a randomised clinical trial.

INTRODUCTION: Rotator cuff calcific tendinopathy (RCCT) involves calcific deposits in the rotator cuff. Non-surgical interventions such as extracorporeal shockwave therapy (ESWT) and ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT) are recommended for its early management. Exercise therapy (ET) has shown to be an effective intervention for people with rotator cuff tendinopathy, but it has not been formally tested in RCCT. The main objective of this study is to compare the effectiveness of an ET programme with ESWT and US-PICT in people with RCCT. As a secondary aim, this study aims to describe the natural history of RCCT. METHODS AND ANALYSIS: A randomised, single-blinded four-group clinical trial will be conducted. Adults from 30 to 75 years diagnosed with RCCT who accomplish eligibility criteria will be recruited. Participants (n=116) will be randomised into four groups: ET group will receive a 12-week rehabilitation programme; ESWT group will receive four sessions with 1 week rest between sessions during 1 month; US-PICT group will receive two sessions with 3 months of rest between sessions; and (actual) wait-and-see group will not receive any intervention during the 12-month follow-up. The primary outcome will be shoulder pain assessed with the Shoulder Pain and Disability Index at baseline, 2 weeks, 4 months, 6 months and 12 months from baseline. The primary analysis will be performed at 12 months from baseline. Secondary outcomes will include pain, range of motion, patient satisfaction and imaging-related variables. Moreover, the following psychosocial questionnaires with their corresponding outcome measure will be assessed: Central Sensitization Inventory (symptoms related to central sensitization); Pain Catastrophizing Scale (pain catastrophizing); Tampa Scale for Kinesiophobia 11 items (fear of movement); Fear Avoidance Belief Questionnaire (fear avoidance behaviour); Hospital Anxiety and Depression Scale (anxiety and depression); Pittsburgh Sleep Quality Index (sleep quality); and the EuroQol-5D (quality of life). An intention-to-treat analysis will be performed to reduce the risk of bias using a worst-case and best-case scenario analysis. ETHICS AND DISSEMINATION: Ethics committee approval for this study has been obtained (reference number: 1718862). The results of the main trial will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT05478902.

Neck or Shoulder? Establishing Consensus for Spine Screening in Patients with Shoulder Pain: an International Modified Delphi Study.

OBJECTIVE: There is no established consensus for screening the spine in patients with shoulder pain. The aim of this study was to explore the role of the spine in shoulder pain and generate a set of recommendations for assessing the potential involvement of the spine in patients with shoulder pain. METHODS: A modified Delphi study was conducted through use of an international shoulder physical therapist's expert panel. Three domains (clinical reasoning, history, physical examination) were evaluated using a Likert scale, with consensus defined as Aiken Validity Index ≥0.7. RESULTS: Twenty-two physical therapists participated. Consensus was reached on a total of 30 items: clinical reasoning (n = 9), history (n = 13), and physical examination (n = 8). The statement that spinal and shoulder disorders can coexist, sometimes influencing each other and at other times remaining independent issues, along with the concept of radiating pain as an explanatory phenomenon for the spine contribution to shoulder pain, achieved the highest degree of consensus. CONCLUSION: International physical therapists shoulder experts reached consensus on key aspects when screening the spine in people with shoulder pain, including consideration of the distal location of symptoms relative to the shoulder, the presence or previous history of neck pain, the changes in symptoms related to neck movements, and the presence of neuropathic-like symptoms. They also acknowledged the importance of assessing active cervical or cervicothoracic movements and the usefulness of the Spurling test and symptom modification techniques applied to the spine.

Structural and functional brain changes in people with knee osteoarthritis: a scoping review.

Background: Knee osteoarthritis is a highly prevalent disease worldwide that leads to functional disability and chronic pain. It has been shown that not only changes are generated at the joint level in these individuals, but also neuroplastic changes are produced in different brain areas, especially in those areas related to pain perception, therefore, the objective of this research was to identify and compare the structural and functional brain changes in knee OA versus healthy subjects. Methodology: Searches in MEDLINE (PubMed), EMBASE, WOS, CINAHL, SCOPUS, Health Source, and Epistemonikos databases were conducted to explore the available evidence on the structural and functional brain changes occurring in people with knee OA. Data were recorded on study characteristics, participant characteristics, and brain assessment techniques. The methodological quality of the studies was analysed with Newcastle Ottawa Scale. Results: Sixteen studies met the inclusion criteria. A decrease volume of the gray matter in the insular region, parietal lobe, cingulate cortex, hippocampus, visual cortex, temporal lobe, prefrontal cortex, and basal ganglia was found in people with knee OA. However, the opposite occurred in the frontal lobe, nucleus accumbens, amygdala region and somatosensory cortex, where an increase in the gray matter volume was evidenced. Moreover, a decreased connectivity to the frontal lobe from the insula, cingulate cortex, parietal, and temporal areas, and an increase in connectivity from the insula to the prefrontal cortex, subcallosal area, and temporal lobe was shown. Conclusion: All these findings are suggestive of neuroplastic changes affecting the pain matrix in people with knee OA.

A scoping review of tendon transfer surgeries and postsurgical physical therapy interventions in individuals with massive rotator cuff tears.

OBJECTIVE: To identify tendon transfer surgeries and postsurgical physical therapy interventions in people with massive rotator cuff (RC) tears. METHODS: The literature search was conducted in the MEDLINE, Science Direct, Scopus, Web of Science, and PEDro databases from inception to September 2022. Studies with patients diagnosed with massive RC tears undergoing tendon transfers that reported physical therapy interventions after surgery were included. Two reviewers pooled the data into ad hoc summary tables with the following information: authors, year, study characteristics (sample size, tendon transfer surgical used, approach type, preoperative risk, deficit addressed, additional surgical interventions), and physical therapy interventions (early stage, intermediate stage, and advanced stage). RESULTS: Forty-four articles (59.0% case series) were included, with a total sample of 1213 participants. The most frequently used surgery was the isolated tendon transfer of the latissimus dorsi (49.1%). Most of the studies reported three main stages of physical therapy interventions after tendon transfer surgery: early stage (lasting 5-6 weeks), intermediate stage (started at 7-12 weeks), and advanced stage (started at 12 weeks). Physical therapy interventions included passive, active-assisted, resisted therapeutic exercise, and hydrotherapy. CONCLUSIONS: The evidence regarding physical therapy interventions after RC tendon transfer surgery is limited to the number and duration of the stages and general characteristics without specifying the type and dose of the interventions. Future research with high methodological quality should integrate more detailed rehabilitation protocols to better guide therapeutic decisions after RC transfer surgery.

Exploration of the clinical course and longitudinal correlations in frozen shoulder: The role of autonomic function, central pain processing, and psychological variables. A longitudinal multicenter prospective observational study.

BACKGROUND: Altered central pain processing (CPP) and dysautonomia might play a role in the clinical course of frozen shoulder and psychological factors, like pain catastrophizing and hypervigilance, might influence clinical variables in frozen shoulder. OBJECTIVES: To explore the clinical course of frozen shoulder regarding CPP, dysautonomia, pain catastrophizing, and hypervigilance and to explore whether longitudinal correlations between these outcomes and pain intensity were present. DESIGN: prospective longitudinal observational study. METHOD: Participants with frozen shoulder were recruited at hospitals and general practitioner practices and followed for 9 months. They completed six questionnaires (about demographics, shoulder pain and disability, pain intensity, pain catastrophizing, pain hypervigilance, and autonomic symptoms) and underwent tactile sensitivity (allodynia), pressure pain thresholds (hyperalgesia), temporal summation, and conditioned pain modulation during four timeframes (3-month intervals). RESULTS: Initially, 149 participants with frozen shoulder were recruited and 88 completed all the measurements. An improvement from baseline to at least one follow-up measurement was found for shoulder pain and disability, pain intensity, pain catastrophizing, hypervigilance, and dysautonomia. A fair longitudinal correlation was found between pain intensity and catastrophizing and hypervigilance (r = 0.301-0.397). Poor longitudinal correlations were found between pain intensity and allodynia and hyperalgesia (r = -0.180-0.193), between pain catastrophizing and dysautonomia (r = 0.209) and between hypervigilance and hyperalgesia (r = -0.159). CONCLUSION: Patients with frozen shoulder showed an early improvement that flattened with time in several pain and psychological variables over the course of 9 months. However, autonomic symptoms rather showed a late improvement over 9 months.

Autonomic Nervous System Function and Central Pain Processing in People With Frozen Shoulder: A Case-control Study.

OBJECTIVES: The pathophysiology of a frozen shoulder (FS) is thought to be related to chronic inflammation. Chronic inflammation may disturb the immune system and consequently the nervous system as part of an overarching system. The aim of this study was to determine the presence of disturbed autonomic nervous system function and altered central pain processing (CPP) in patients with FS. Secondarily, the presence of psychological variables (catastrophizing and hypervigilance) and self-reported associated symptoms of altered CPP in patients with FS were investigated. METHODS: Patients with FS and healthy controls completed the Composite Autonomic Symptom Score (autonomic function) and underwent quantitative sensory testing to assess tactile sensitivity (ie, allodynia), pressure pain thresholds (PPTs, ie, hyperalgesia), temporal summation of pain, and Conditioned Pain Modulation (CPM). Psychological issues were explored with the Pain Catastrophizing Scale and the Pain Vigilance and Awareness Questionnaire, and self-reported symptoms associated with altered CPP were determined with the Central Sensitization Inventory. RESULTS: Thirty-two patients with FS and 35 healthy controls were analyzed in the study. Patients with FS showed more self-reported autonomic symptoms and symptoms of altered CPP, higher levels of pain catastrophizing and hypervigilance, and are more sensitive to tactile touches and mechanical pressure compared with controls. DISCUSSION: On the basis of the effect sizes, between-group differences in allodynia, hyperalgesia, catastrophizing, and hypervigilance were clinically relevant, but only local allodynia, hyperalgesia, catastrophizing, and hypervigilance were statistically different. Therefore, obvious altered CPP was not present at the group level in patients with FS compared with controls.

Effectiveness of two video-based multicomponent treatments for fibromyalgia: The added value of cognitive restructuring and mindfulness in a three-arm randomised controlled trial.

BACKGROUND/OBJECTIVES: The aim of this study was to examine the effectiveness of two video-based multicomponent programs (FIBROWALK) and the Multicomponent Physiotherapy Program (MPP) for patients with fibromyalgia (FM) compared to treatment-as-usual (TAU) only. We posit that FIBROWALK, due to inclusion of specific psychological ingredients (cognitive restructuring and mindfulness), can produce additional clinical benefits when compared to TAU or MPP alone. METHODS: A total of 330 patients with FM were recruited and randomly allocated (1:1:1) to TAU only, TAU + FIBROWALK, or TAU + MPP. FIBROWALK and MPP consisted of weekly videos on pain neuroscience education, therapeutic exercise and self-management patient education, but only the FIBROWALK intervention provided cognitive restructuring and mindfulness. Both programs were structurally equivalent. Between-group differences in functional impairment, pain, kinesiophobia, anxious-depressive symptoms and physical functioning were evaluated at post-treatment following Intention-To-Treat and complete-case approaches. RESULTS: Compared to TAU only, individuals in the FIBROWALK arm showed larger improvements in all clinical outcomes; similarly, participants in the MPP program also showed greater improvements in functional impairment, perceived pain, kinesiophobia, depressive symptoms compared to TAU only. The FIBROWALK intervention showed superior effects in improving pain, anxiety and depressive symptoms and physical functioning compared to MPP. CONCLUSIONS: This RCT supports the short-term effectiveness of the video-based multicomponent programs FIBROWALK and MPP for FM and provides evidence that cognitive-behavioural and mindfulness-based techniques can be clinically useful in the context of physiotherapeutic multicomponent treatment programs. TRIAL REGISTRATION NUMBER: NCT04571528.

Understanding the clinical profile of patients with frozen shoulder: a longitudinal multicentre observational study.

INTRODUCTION: There is a large diversity in the clinical presentation of frozen shoulder (FS) and the clinical outcome is not always satisfactory. The aim of the current study was to examine to what extent range of motion (ROM) limitation, metabolic factors (diabetes mellitus and thyroid disorders), autonomic symptoms and pain sensitivity may contribute to the prognosis in terms of shoulder pain and disability and quality of life in patients with FS. METHODS: Patients with stage 1 or 2 FS were longitudinally followed-up during 9 months after baseline assessment. They completed six questionnaires and underwent quantitative sensory testing (pressure pain thresholds, temporal summation and conditioned pain modulation) and ROM assessment. RESULTS: One hundred and forty-nine patients with FS were initially recruited and 121 completed at least one follow-up measurement. Shoulder pain and disability improved over time and diabetes mellitus was found to be a prognostic factor for final outcome. Several domains of quality of life also improved over time and external rotation ROM, diabetes mellitus, thyroid disorder and autonomic symptoms were found to be prognostic factors for final outcome. These prognostic factors explained 2.5%-6.3% of the final outcome of shoulder pain and disability and quality of life. DISCUSSION AND CONCLUSION: In patients with FS, prognostic variables were able to predict different outcomes, indicating that outcomes in this population can be variable-dependent. Other variables not explored in this study might contribute to the prognosis of patients with FS, which should be investigated in future research. In clinical practice, baseline assessment of prognostic factors and focusing on a more holistic approach might be useful to inform healthcare practitioners about progression of patients with FS during a 9-month period.