Interventions for treating pain and disability in adults with complex regional pain syndrome- an overview of systematic reviews.

BACKGROUND: Complex regional pain syndrome (CRPS) is a chronic pain condition that usually occurs in a limb following trauma or surgery. It is characterised by persisting pain that is disproportionate in magnitude or duration to the typical course of pain after similar injury. There is currently no consensus regarding the optimal management of CRPS, although a broad range of interventions have been described and are commonly used. This is the first update of the original Cochrane review published in Issue 4, 2013. OBJECTIVES: To summarise the evidence from Cochrane and non-Cochrane systematic reviews of the efficacy, effectiveness, and safety of any intervention used to reduce pain, disability, or both, in adults with CRPS. METHODS: We identified Cochrane reviews and non-Cochrane reviews through a systematic search of Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, CINAHL, PEDro, LILACS and Epistemonikos from inception to October 2022, with no language restrictions. We included systematic reviews of randomised controlled trials that included adults (≥18 years) diagnosed with CRPS, using any diagnostic criteria.  Two overview authors independently assessed eligibility, extracted data, and assessed the quality of the reviews and certainty of the evidence using the AMSTAR 2 and GRADE tools respectively. We extracted data for the primary outcomes pain, disability and adverse events, and the secondary outcomes quality of life, emotional well-being, and participants' ratings of satisfaction or improvement with treatment.  MAIN RESULTS: We included six Cochrane and 13 non-Cochrane systematic reviews in the previous version of this overview and five Cochrane and 12 non-Cochrane reviews in the current version. Using the AMSTAR 2 tool, we judged Cochrane reviews to have higher methodological quality than non-Cochrane reviews. The studies in the included reviews were typically small and mostly at high risk of bias or of low methodological quality. We found no high-certainty evidence for any comparison.  There was low-certainty evidence that bisphosphonates may reduce pain intensity post-intervention (standardised mean difference (SMD) -2.6, 95% confidence interval (CI) -1.8 to -3.4, P = 0.001; I2 = 81%; 4 trials, n = 181) and moderate-certainty evidence that they are probably associated with increased adverse events of any nature (risk ratio (RR) 2.10, 95% CI 1.27 to 3.47; number needed to treat for an additional harmful outcome (NNTH) 4.6, 95% CI 2.4 to 168.0; 4 trials, n = 181).  There was moderate-certainty evidence that lidocaine local anaesthetic sympathetic blockade probably does not reduce pain intensity compared with placebo, and low-certainty evidence that it may not reduce pain intensity compared with ultrasound of the stellate ganglion. No effect size was reported for either comparison. There was low-certainty evidence that topical dimethyl sulfoxide may not reduce pain intensity compared with oral N-acetylcysteine, but no effect size was reported. There was low-certainty evidence that continuous bupivacaine brachial plexus block may reduce pain intensity compared with continuous bupivacaine stellate ganglion block, but no effect size was reported. For a wide range of other commonly used interventions, the certainty in the evidence was very low and provides insufficient evidence to either support or refute their use. Comparisons with low- and very low-certainty evidence should be treated with substantial caution. We did not identify any RCT evidence for routinely used pharmacological interventions for CRPS such as tricyclic antidepressants or opioids. AUTHORS' CONCLUSIONS: Despite a considerable increase in included evidence compared with the previous version of this overview, we identified no high-certainty evidence for the effectiveness of any therapy for CRPS. Until larger, high-quality trials are undertaken, formulating an evidence-based approach to managing CRPS will remain difficult. Current non-Cochrane systematic reviews of interventions for CRPS are of low methodological quality and should not be relied upon to provide an accurate and comprehensive summary of the evidence.

Pain science and practice as a 'threshold concept' within undergraduate and pre-registration physiotherapy education: a jewel of the curriculum?

BACKGROUND: Threshold concepts describe learning experiences that transform our understanding of a concept. Threshold concepts are variously: troublesome, transformative, irreversible, integrative and bounded. PURPOSE: The aim of this narrative review is to consider the case for characterising pain science and practice as a threshold concept within undergraduate and pre-registration physiotherapy education. This article considers the underlying tenets of threshold concepts as they relate to teaching and learning and the relative merits and limitations of characterising pain science and practice as a threshold concept within undergraduate and pre-registration physiotherapy education from both pedagogical and epidemiological perspectives. By evaluating pain, as it relates to physiotherapy education and practice, according to the five defining characteristics of a threshold concept then presenting data related to the epidemiology and impact of pain, the worthiness of characterising pain science and practice as a threshold concept will be discussed and further debate invited.

Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II.

BACKGROUND: Complex regional pain syndrome (CRPS) is a painful and disabling condition that usually manifests in response to trauma or surgery and is associated with significant pain and disability. CRPS can be classified into two types: type I (CRPS I) in which a specific nerve lesion has not been identified and type II (CRPS II) where there is an identifiable nerve lesion. Guidelines recommend the inclusion of a variety of physiotherapy interventions as part of the multimodal treatment of people with CRPS. This is the first update of the review originally published in Issue 2, 2016. OBJECTIVES: To determine the effectiveness of physiotherapy interventions for treating pain and disability associated with CRPS types I and II in adults. SEARCH METHODS: For this update we searched CENTRAL (the Cochrane Library), MEDLINE, Embase, CINAHL, PsycINFO, LILACS, PEDro, Web of Science, DARE and Health Technology Assessments from February 2015 to July 2021 without language restrictions, we searched the reference lists of included studies and we contacted an expert in the field. We also searched additional online sources for unpublished trials and trials in progress. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of physiotherapy interventions compared with placebo, no treatment, another intervention or usual care, or other physiotherapy interventions in adults with CRPS I and II. Primary outcomes were pain intensity and disability. Secondary outcomes were composite scores for CRPS symptoms, health-related quality of life (HRQoL), patient global impression of change (PGIC) scales and adverse effects. DATA COLLECTION AND ANALYSIS: Two review authors independently screened database searches for eligibility, extracted data, evaluated risk of bias and assessed the certainty of evidence using the GRADE system. MAIN RESULTS: We included 16 new trials (600 participants) along with the 18 trials from the original review totalling 34 RCTs (1339 participants). Thirty-three trials included participants with CRPS I and one trial included participants with CRPS II. Included trials compared a diverse range of interventions including physical rehabilitation, electrotherapy modalities, cortically directed rehabilitation, electroacupuncture and exposure-based approaches. Most interventions were tested in small, single trials. Most were at high risk of bias overall (27 trials) and the remainder were at 'unclear' risk of bias (seven trials). For all comparisons and outcomes where we found evidence, we graded the certainty of the evidence as very low, downgraded due to serious study limitations, imprecision and inconsistency. Included trials rarely reported adverse effects. Physiotherapy compared with minimal care for adults with CRPS I One trial (135 participants) of multimodal physiotherapy, for which pain data were unavailable, found no between-group differences in pain intensity at 12-month follow-up. Multimodal physiotherapy demonstrated a small between-group improvement in disability at 12 months follow-up compared to an attention control (Impairment Level Sum score, 5 to 50 scale; mean difference (MD) -3.7, 95% confidence interval (CI) -7.13 to -0.27) (very low-certainty evidence). Equivalent data for pain were not available. Details regarding adverse events were not reported. Physiotherapy compared with minimal care for adults with CRPS II We did not find any trials of physiotherapy compared with minimal care for adults with CRPS II. AUTHORS' CONCLUSIONS: The evidence is very uncertain about the effects of physiotherapy interventions on pain and disability in CRPS. This conclusion is similar to our 2016 review. Large-scale, high-quality RCTs with longer-term follow-up are required to test the effectiveness of physiotherapy-based interventions for treating pain and disability in adults with CRPS I and II.

Nervous System Sensitization as a Predictor of Outcome in the Treatment of Peripheral Musculoskeletal Conditions: A Systematic Review.

BACKGROUND: Research suggests that peripheral and central nervous system sensitization can contribute to the overall pain experience in peripheral musculoskeletal (MSK) conditions. It is unclear, however, whether sensitization of the nervous system results in poorer outcomes following the treatment. This systematic review investigated whether nervous system sensitization in peripheral MSK conditions predicts poorer clinical outcomes in response to a surgical or conservative intervention. METHODS: Four electronic databases were searched to identify the relevant studies. Eligible studies had a prospective design, with a follow-up assessing the outcome in terms of pain or disability. Studies that used baseline indices of nervous system sensitization were included, such as quantitative sensory testing (QST) or questionnaires that measured centrally mediated symptoms. RESULTS: Thirteen studies met the inclusion criteria, of which six were at a high risk of bias. The peripheral MSK conditions investigated were knee and hip osteoarthritis, shoulder pain, and elbow tendinopathy. QST parameters indicative of sensitization (lower electrical pain thresholds, cold hyperalgesia, enhanced temporal summation, lower punctate sharpness thresholds) were associated with negative outcome (more pain or disability) in 5 small exploratory studies. Larger studies that accounted for multiple confounders in design and analysis did not support a predictive relationship between QST parameters and outcome. Two studies used self-report measures to capture comorbid centrally mediated symptoms, and found higher questionnaire scores were independently predictive of more persistent pain following a total joint arthroplasty. CONCLUSION: This systematic review found insufficient evidence to support an independent predictive relationship between QST measures of nervous system sensitization and treatment outcome. Self-report measures demonstrated better predictive ability. Further high-quality prognostic research is warranted.

Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II.

BACKGROUND: Complex regional pain syndrome (CRPS) is a painful and disabling condition that usually manifests in response to trauma or surgery. When it occurs, it is associated with significant pain and disability. It is thought to arise and persist as a consequence of a maladaptive pro-inflammatory response and disturbances in sympathetically-mediated vasomotor control, together with maladaptive peripheral and central neuronal plasticity. CRPS can be classified into two types: type I (CRPS I) in which a specific nerve lesion has not been identified, and type II (CRPS II) where there is an identifiable nerve lesion. Guidelines recommend the inclusion of a variety of physiotherapy interventions as part of the multimodal treatment of people with CRPS, although their effectiveness is not known. OBJECTIVES: To determine the effectiveness of physiotherapy interventions for treating the pain and disability associated with CRPS types I and II. SEARCH METHODS: We searched the following databases from inception up to 12 February 2015: CENTRAL (the Cochrane Library), MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, PEDro, Web of Science, DARE and Health Technology Assessments, without language restrictions, for randomised controlled trials (RCTs) of physiotherapy interventions for treating pain and disability in people CRPS. We also searched additional online sources for unpublished trials and trials in progress. SELECTION CRITERIA: We included RCTs of physiotherapy interventions (including manual therapy, therapeutic exercise, electrotherapy, physiotherapist-administered education and cortically directed sensory-motor rehabilitation strategies) employed in either a stand-alone fashion or in combination, compared with placebo, no treatment, another intervention or usual care, or of varying physiotherapy interventions compared with each other in adults with CRPS I and II. Our primary outcomes of interest were patient-centred outcomes of pain intensity and functional disability. DATA COLLECTION AND ANALYSIS: Two review authors independently evaluated those studies identified through the electronic searches for eligibility and subsequently extracted all relevant data from the included RCTs. Two review authors independently performed 'Risk of bias' assessments and rated the quality of the body of evidence for the main outcomes using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: We included 18 RCTs (739 participants) that tested the effectiveness of a broad range of physiotherapy-based interventions. Overall, there was a paucity of high quality evidence concerning physiotherapy treatment for pain and disability in people with CRPS I. Most included trials were at 'high' risk of bias (15 trials) and the remainder were at 'unclear' risk of bias (three trials). The quality of the evidence was very low or low for all comparisons, according to the GRADE approach.We found very low quality evidence that graded motor imagery (GMI; two trials, 49 participants) may be useful for improving pain (0 to 100 VAS) (mean difference (MD) -21.00, 95% CI -31.17 to -10.83) and functional disability (11-point numerical rating scale) (MD 2.30, 95% CI 1.12 to 3.48), at long-term (six months) follow-up, in people with CRPS I compared to usual care plus physiotherapy; very low quality evidence that multimodal physiotherapy (one trial, 135 participants) may be useful for improving 'impairment' at long-term (12 month) follow-up compared to a minimal 'social work' intervention; and very low quality evidence that mirror therapy (two trials, 72 participants) provides clinically meaningful improvements in pain (0 to 10 VAS) (MD 3.4, 95% CI -4.71 to -2.09) and function (0 to 5 functional ability subscale of the Wolf Motor Function Test) (MD -2.3, 95% CI -2.88 to -1.72) at long-term (six month) follow-up in people with CRPS I post stroke compared to placebo (covered mirror).There was low to very low quality evidence that tactile discrimination training, stellate ganglion block via ultrasound and pulsed electromagnetic field therapy compared to placebo, and manual lymphatic drainage combined with and compared to either anti-inflammatories and physical therapy or exercise are not effective for treating pain in the short-term in people with CRPS I. Laser therapy may provide small clinically insignificant, short-term, improvements in pain compared to interferential current therapy in people with CRPS I.Adverse events were only rarely reported in the included trials. No trials including participants with CRPS II met the inclusion criteria of this review. AUTHORS' CONCLUSIONS: The best available data show that GMI and mirror therapy may provide clinically meaningful improvements in pain and function in people with CRPS I although the quality of the supporting evidence is very low. Evidence of the effectiveness of multimodal physiotherapy, electrotherapy and manual lymphatic drainage for treating people with CRPS types I and II is generally absent or unclear. Large scale, high quality RCTs are required to test the effectiveness of physiotherapy-based interventions for treating pain and disability of people with CRPS I and II. Implications for clinical practice and future research are considered.

Intraexaminer and interexaminer reliability of manual palpation and pressure algometry of the lower limb nerves in asymptomatic subjects.

OBJECTIVE: Nerve palpation is a method of clinically identifying mechanosensitivity of neural tissue by means of pressure algometry and manual palpation. There are few investigations of the reliability of lower limb nerve palpation, and femoral nerve palpation has never been previously reported. The aim of this study was to investigate the reliability of nerve palpation of the femoral, sciatic, tibial, and common peroneal nerves and to report normative values for the femoral nerve. METHODS: The 4 lower limb nerves were palpated in 39 healthy volunteers using pressure algometry and manual digital palpation. Measurements were taken twice by 1 rater (intrarater reliability) and once by a second rater (interrater reliability). RESULTS: Intraclass correlation coefficients for pressure pain thresholds (PPTs) via pressure algometry of the femoral, common peroneal, tibial, and sciatic nerves were 0.69, 0.84, 0.64, and 0.9 for intrarater reliability, respectively, and 0.82, 0.7, 0.56, and 0.75 for interrater reliability. κ Values for manual palpation were 0.59, 0.55, 0.42, and 0.60 for intrarater reliability and 0.30, 0.49, 0.37, and 0.60 for interrater reliability. Males demonstrated significantly higher PPTs than females for the femoral, sciatic, and tibial nerves, and differences in PPTs were present between right and left sides. CONCLUSION: Nerve palpation of the femoral, common peroneal, and sciatic nerves using pressure algometry demonstrated good to excellent reliability, whereas the tibial nerve PPTs showed moderate to good reliability. Manual palpation measurements demonstrated fair to moderate reliability.

A survey of physiotherapist managers in Ireland and their views on the role of Advanced Practice Physiotherapists.

BACKGROUND: Within the current context of implementation of an Advanced Practice Grade, the Irish Society of Chartered Physiotherapists commissioned a survey of physiotherapy manager opinions regarding the role of Advanced Practice Physiotherapists. OBJECTIVES: The aim of this survey was to explore the views of physiotherapist managers in relation to the characteristics, role, competencies and management of Advanced Practice Physiotherapists (APPs) in Ireland. METHODS: Physiotherapist managers based in primary and secondary care settings in Ireland were invited to participate in a survey on Advanced Practice. Quantitative data from a custom designed online survey was analysed with descriptive statistics and qualitative data from open-ended survey questions were analysed using thematic analysis. RESULTS: The response rate to the survey was 32% (24/75). On average, respondents thought that 54% (range: 15%-80%) of an APPs time should be spent in clinical practice and between 17% and 20% variously on managerial and leadership, teaching and education and research and development duties. Four themes were identified from the surveys' open-ended questions related to the description of APP: 'Extended scope 'Advanced clinical training, knowledge, and decision-making', 'Autonomy, independence and responsibility', and 'Wider roles'. CONCLUSION: Irish physiotherapist managers recognised the extended scope of practice, expertise and multiple roles characteristic of APPs. They indicated the need for legislative changes and clarity around governance.

Physiotherapist managers views on advanced practice physiotherapy in Ireland. A qualitative study.

INTRODUCTION: The introduction of physiotherapists working with advanced scope of practice has contributed to improvements in healthcare services. OBJECTIVE: This qualitative study explores the views of physiotherapist managers on the Advanced Practice Physiotherapy role and the barriers and enablers to progression of this career pathway. METHODS: A qualitative focus group study was conducted online with 10 purposefully sampled physiotherapist managers. The focus groups were audio-recorded, transcribed and thematically analyzed. RESULTS: Three main themes were identified; 1) Physiotherapists working in advanced practice are recognized as experts and strong advocates for the physiotherapy profession; 2) Barriers to Advanced Practice Physiotherapy in Ireland include inconsistent role definition and protection, a lack of legislation and uncertainty concerning clinical governance; and 3) Physiotherapist managers can support Advanced Practice Physiotherapy through mentoring and resource provision, and implementation of the Advanced Practice Competency Framework. CONCLUSION: Physiotherapist managers recognized the value of Advanced Practice Physiotherapy to the Irish health service but suggest that the role and reporting structures need to be clarified. They highlighted barriers preventing the full potential of this these roles being realized and provided suggestions to support the progression of this healthcare model.

The prevalence of chronic pain in adolescents in Central Switzerland: A cross- sectional school-based study protocol.

BACKGROUND: Chronic pain is associated with substantial personal suffering and societal costs and is a growing healthcare concern worldwide. While chronic pain has been extensively studied in adults, limited data exists on its prevalence and impact in adolescents. Understanding the prevalence and impact of chronic pain and pain beliefs in adolescents is crucial for developing effective prevention and treatment strategies. This study aims to estimate the prevalence, characteristics, and impact of chronic pain, and explore adolescents' knowledge and beliefs about pain. METHODS: This is an observational cohort study of school-going adolescents aged 11 to 17 years in Central Switzerland. The study will estimate the point prevalence, characteristics (location, intensity, frequency, duration) and impact (PROMIS Pediatric Short Form v2.0 -Pain Interference Scale, PPIS) of chronic pain in school-going adolescents. We will also measure and investigate pupils' beliefs about pain (Concept of Pain Inventory (COPI)). Data will be collected through manual and digital self-report questionnaires and from participants in primary, secondary, and high schools between September 2023 and January 2024. ANALYSES: The primary analyses will utilise descriptive statistics to estimate the point prevalence, characteristics, and impact of chronic pain. Secondary analyses will analyse associations and correlations between chronic pain, impact of pain and beliefs about pain. OUTCOMES: This study will provide an estimate of the prevalence, characteristics and impact of chronic pain in adolescents in Central Switzerland and a measure of adolescents' understanding and beliefs about pain. In doing so, this study will provide insights into the scale of chronic pain as a public health concern. By understanding adolescents' pain beliefs and their influence on pain experience, this study can contribute to the development of educational approaches to enhance adolescents' knowledge and understanding of pain in order to optimise the prevention and treatment of chronic pain in adolescents. The findings may be useful to healthcare professionals and funders, policymakers, and researchers involved in the prevention, assessment, and treatment of pain in adolescents.

Patients' experiences following total knee arthroplasty: a qualitative evidence synthesis.

PURPOSE: Total knee arthroplasty (TKA) is a common surgical intervention for patients with advanced arthritis. The aim of this qualitative evidence synthesis was to systematically review the qualitative literature on patients' experiences following primary TKA. MATERIALS AND METHODS: Four electronic databases (PubMed, CINAHL, Cochrane and Embase) were searched from inception until October 2021. Pairs of reviewers independently screened search results for eligibility, analysed the quality of included studies and extracted data. We undertook a thematic synthesis and used an interpretive approach to identify recurring themes and draw a conclusion. Data were synthesised using thematic analysis and an interpretive approach was used to identify themes. RESULTS: Twenty-three studies exploring patients' experiences following TKA were included. Five main themes emerged: (i) Experience of healthcare staff, (ii) Pain/Medications, (iii) Was it worth it? (iv) Social Support (v) Follow up. CONCLUSIONS: This review highlights the variability in patients' experiences following TKA. Whether this experience detailed their pain, function, or encounter with healthcare staff or systems, patients reported a variety of both positive and negative sentiments. Each theme invites attention to an area in which healthcare can improve to enhance patients' experiences. The importance of patient support, individualised rehabilitation and appropriate follow-up are highlighted.

This paper reviews patients' experiences after undergoing total knee arthroplasty (TKA)Patients need individualised programmes, made collaboratively with health care professionals, to maximise outcomes and improve motivation.Improved interdisciplinary dialogue and a more holistic approach would increase patients' confidence in their care.Group-based communication classes may offer an improved method for patients to communicate their worries and learn from one another.

The experiences of people living with obesity and chronic pain: A Qualitative Evidence Synthesis (QES) protocol.

INTRODUCTION: There is a substantial and progressive association between chronic pain (CP) and living with overweight or obesity. The relationship between obesity and CP is intricate and complex, with obesity being associated with increased pain-related disability, pain intensity, reduction in physical functioning and poorer psychological well-being. A Qualitative Evidence Synthesis (QES) provides an opportunity to better understand and reveal key areas within the patient experience of these complex interactions to inform best practice and future intervention design. AIMS: The aim of this QES is to methodically and systematically review and synthesise the qualitative literature reporting on the personal experiences of people who are both living with obesity (PwO) and chronic pain. METHODS: The phenomenon of interest of this QES is the lived experiences of PwO and CP. The following research question was developed using a modified Population, Intervention, Comparison, Outcome and Study type (PICOS) framework: "What are the lived experiences of people living with obesity and chronic pain?". One review author will conduct a systematic search based on keywords and Medical Subject Headings (MeSH) terms for finding relevant articles in five peer-review databases, from inception to the date of searching. Two review authors will independently apply inclusion and exclusion criteria and screen articles in a two-stage process. The methodological quality of included studies will be assessed using the Critical Appraisal Skills Programme (CASP) tool and data will be extracted using a customised template. We will undertake a thematic synthesis of qualitative data from included studies and report our findings narratively. Confidence in the findings will be assessed based on the Grading of Recommendations Assessment, Development and Evaluation Confidence in Evidence from Reviews of Qualitative Research (GRADE-CER-Qual) approach. FINDINGS AND DISSEMINATION: This study will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA) and Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines. It is anticipated that the findings of the review will facilitate a deep and broad understanding of the complex interactions between CP and obesity and will help inform best practice and future intervention design. Findings will be disseminated through journals that undergo peer review, presentations at conferences, engagement with public and patient advocacy groups, and social media. ETHICS AND DISSEMINATION: Ethical approval is not required to conduct this review. TRAIL REGISTRATION: PROSPERO registration number: CRD42023361391.

Musculoskeletal Pain: Current and Future Directions of Physical Therapy Practice.

Musculoskeletal (MSK) pain is 1 of the most common problems managed by clinicians in MSK care. This article reviews current frameworks for the assessment and management of MSK pain within evidence-based physical therapy practice. Key considerations related to the biopsychosocial model of pain, evidence-based practice, assessment, treatment, physical activity/movement behavior, risk stratification, communication as well as patient education and self-management skills within physical therapy and physical and rehabilitation medicine are addressed. The future direction of MSK pain management is also discussed, including strategies to promote evidence-based practice, behavior change, social prescribing, and the use of technologies.

Exercise combined with Acceptance and Commitment Therapy compared with a standalone supervised exercise programme for adults with chronic pain: a randomised controlled trial.

ABSTRACT: A prospective, 2-armed, parallel group randomised controlled trial (RCT) was conducted to compare the effectiveness of Acceptance and Commitment Therapy (ACT) combined with a supervised exercise programme with a supervised exercise programme alone for adults with chronic pain. One hundred seventy-five participants were individually randomised to receive either the combined Exercise and ACT (ExACT) intervention or supervised exercise alone. Those allocated to the ExACT group attended 8 weekly sessions with a psychologist based on the ACT approach, in addition to supervised exercise classes led by a physiotherapist. The control group attended weekly supervised exercise classes but did not take part in an ACT programme. Both groups were followed up postintervention and again after 12 weeks. The primary outcome was pain interference at 12-week follow-up. Estimates of treatment effects at follow-up were based on intention-to-treat analyses, implemented using a linear mixed-effects model. The findings of this RCT showed no difference in the effectiveness of ExACT, compared with a supervised exercise programme alone for the primary outcome pain interference at 12-week follow-up (mean difference -0.18, 95% confidence interval -0.84 to 0.48, P = 0.59, d = 0.11). ExACT group participants reported superior outcomes for pain self-efficacy, pain catastrophising, and committed action, compared with the control group, but there were no differences between the groups for other secondary outcomes or treatment process measures. Higher levels of treatment satisfaction and global impression of change were reported by ExACT group participants. Exercise combined with Acceptance and Commitment Therapy was not superior to a standalone supervised exercise programme for reducing pain interference in adults with chronic pain.

Multidimensional pain profiling in people living with obesity and attending weight management services: a protocol for a longitudinal cohort study.

INTRODUCTION: Pain is prevalent in people living with overweight and obesity. Obesity is associated with increased self-reported pain intensity and pain-related disability, reductions in physical functioning and poorer psychological well-being. People living with obesity tend to respond less well to pain treatments or management compared with people living without obesity. Mechanisms linking obesity and pain are complex and may include contributions from and interactions between physiological, behavioural, psychological, sociocultural, biomechanical and genetic factors. Our aim is to study the multidimensional pain profiles of people living with obesity, over time, in an attempt to better understand the relationship between obesity and pain. METHODS AND ANALYSIS: This longitudinal observational cohort study will recruit (n=216) people living with obesity and who are newly attending three weight management services in Ireland. Participants will complete questionnaires that assess their multidimensional biopsychosocial pain experience at baseline and at 3, 6, 12 and 18 months post-recruitment. Quantitative analyses will characterise the multidimensional pain experiences and trajectories of the cohort as a whole and in defined subgroups. ETHICS AND DISSEMINATION: The study protocol has been approved by the Ethics and Medical Research Committee of St Vincent's Healthcare Group, Dublin, Ireland (reference no: RS21-059) and the University College Dublin Human Research Ethics Committee (reference no: LS-E-22-41-Hinwood-Smart). Findings will be disseminated through peer-reviewed journals, conference presentations, public and patient advocacy groups, and social media. STUDY REGISTRATION: Open Science Framework Registration DOI: https://doi.org/10.17605/OSF.IO/QCWUE.

Features and methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system: a Delphi expert consensus study.

ABSTRACT: Classification of musculoskeletal pain based on underlying pain mechanisms (nociceptive, neuropathic, and nociplastic pain) is challenging. In the absence of a gold standard, verification of features that could aid in discrimination between these mechanisms in clinical practice and research depends on expert consensus. This Delphi expert consensus study aimed to: (1) identify features and assessment findings that are unique to a pain mechanism category or shared between no more than 2 categories and (2) develop a ranked list of candidate features that could potentially discriminate between pain mechanisms. A group of international experts were recruited based on their expertise in the field of pain. The Delphi process involved 2 rounds: round 1 assessed expert opinion on features that are unique to a pain mechanism category or shared between 2 (based on a 40% agreement threshold); and round 2 reviewed features that failed to reach consensus, evaluated additional features, and considered wording changes. Forty-nine international experts representing a wide range of disciplines participated. Consensus was reached for 196 of 292 features presented to the panel (clinical examination-134 features, quantitative sensory testing-34, imaging and diagnostic testing-14, and pain-type questionnaires-14). From the 196 features, consensus was reached for 76 features as unique to nociceptive (17), neuropathic (37), or nociplastic (22) pain mechanisms and 120 features as shared between pairs of pain mechanism categories (78 for neuropathic and nociplastic pain). This consensus study generated a list of potential candidate features that are likely to aid in discrimination between types of musculoskeletal pain.

Metagenomic analysis of apple orchard soil reveals antibiotic resistance genes encoding predicted bifunctional proteins.

To gain insight into the diversity and origins of antibiotic resistance genes, we identified resistance genes in the soil in an apple orchard using functional metagenomics, which involves inserting large fragments of foreign DNA into Escherichia coli and assaying the resulting clones for expressed functions. Among 13 antibiotic-resistant clones, we found two genes that encode bifunctional proteins. One predicted bifunctional protein confers resistance to ceftazidime and contains a natural fusion between a predicted transcriptional regulator and a beta-lactamase. Sequence analysis of the entire metagenomic clone encoding the predicted bifunctional beta-lactamase revealed a gene potentially involved in chloramphenicol resistance as well as a predicted transposase. A second clone that encodes a predicted bifunctional protein confers resistance to kanamycin and contains an aminoglycoside acetyltransferase domain fused to a second acetyltransferase domain that, based on nucleotide sequence, was predicted not to be involved in antibiotic resistance. This is the first report of a transcriptional regulator fused to a beta-lactamase and of an aminoglycoside acetyltransferase fused to an acetyltransferase not involved in antibiotic resistance.

Multidisciplinary-based Rehabilitation (MBR) Compared With Active Physical Interventions for Pain and Disability in Adults With Chronic Pain: A Systematic Review and Meta-analysis.

OBJECTIVE: This systematic review and meta-analysis examined the effectiveness of multidisciplinary-based rehabilitation (MBR) in comparison with active physical interventions for adults with chronic pain. MATERIALS AND METHODS: The review was conducted in line with the recommendations provided in the Cochrane Handbook for Systematic Reviews and is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 8 electronic databases were searched from inception to November 2018. Only randomized controlled trials were eligible for inclusion. In total, 31 trials were identified, and most studies involved patients with chronic low back pain (25 trials). The main outcomes considered were pain intensity and disability at short-term follow-up (≤3 mo after treatment), medium-term follow-up (>3 and <12 mo), and long-term follow-up (≥12 mo). The quality of the evidence was assessed according to the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach RESULTS:: A total of 27 studies were included in the meta-analysis. Statistically significant differences in favor of MBR were found for pain intensity and disability at short-term follow-up (standardized mean difference=0.53 and 0.50) and long-term follow-up (standardized mean difference=0.56 and 0.77), but the quality of the evidence was low. There was no significant difference between MBR and active physical interventions in the medium-term follow-up. CONCLUSIONS: Overall, the results suggest that MBR may lead to greater improvements in pain intensity and disability compared with active physical interventions, and the effects appear to be sustained in the long term. However, these findings should be interpreted with caution in light of the low quality of the evidence, with all but one trial judged to be at high risk of bias. Further research is required to assess the effectiveness of MBR for people with chronic pain conditions other than low back pain.

The Relationship Between Clinical and Quantitative Measures of Pain Sensitization in Knee Osteoarthritis.

OBJECTIVES: Pain sensitization in knee osteoarthritis (OA) is associated with greater symptom severity and poorer clinical outcomes. Measures that identify pain sensitization and are accessible to use in clinical practice have been suggested to enable more targeted treatments. This merits further investigation. This study examines the relationship between quantitative sensory testing (QST) and clinical measures of pain sensitization in people with knee OA. METHODS: A secondary analysis of data from 134 participants with knee OA was performed. Clinical measures included: manual tender point count (MTPC), the Central Sensitization Inventory (CSI) to capture centrally mediated comorbidities, number of painful sites on a body chart, and neuropathic pain-like symptoms assessed using the modified PainDetect Questionnaire. Relationships between clinical measures and QST measures of pressure pain thresholds (PPTs), temporal summation, and conditioned pain modulation were investigated using correlation and multivariable regression analyses. RESULTS: Fair to moderate correlations, ranging from -0.331 to -0.577 (P<0.05), were identified between MTPC, the CSI, number of painful sites, and PPTs. Fair correlations, ranging from 0.28 to 0.30 (P<0.01), were identified between MTPC, the CSI, number of painful sites, and conditioned pain modulation. Correlations between the clinical and self-reported measures and temporal summation were weak and inconsistent (0.09 to 0.25). In adjusted regression models, MTPC was the only clinical measure consistently associated with QST and accounted for 11% to 12% of the variance in PPTs. DISCUSSION: MTPC demonstrated the strongest associations with QST measures and may be the most promising proxy measure to detect pain sensitization clinically.

Advanced musculoskeletal physiotherapy practice: The patient journey and experience.

BACKGROUND: As many patients referred to orthopaedic and rheumatology services do not require medical or surgical interventions, advanced practice physiotherapists (APPs) have been introduced into hospital services to triage the care of these patients. Patient perspectives are critical to review the acceptance of this model of care and potential for expansion into primary care. This study aimed to explore the clinical journeys, and the experiences and perceptions of patients attending APP services. METHOD: Semi-structured interviews (n = 10) were conducted with patients across two hospital sites, with narrative data subjected to a thematic analysis. MSK journeys were mapped via medical chart and interview data, with surveys collecting demographics. RESULTS: Patient journeys involved multiple contact points and some duplication in MSK health services. Overall, experiences of the APP service were positive, with faster access into the hospital system and patients valued the interpersonal and professional skills of the APP. Having already attended a physiotherapist, some patients did have a preconception of what the APP could offer them. However, initial concerns were mitigated following the APP appointment, as the APP had extensive MSK knowledge. Hospitals remained the preferred location for MSK appointments due to availability of diagnostics and 'specialists', and close proximity of the doctor. CONCLUSION: Patients were positive about the new MSK APP service and benefits related to shorter wait times and seeing a specialist who listened and involved them in their management. However, a cultural shift regarding patient perceptions of the 'specialists' in hospitals and the role of a physiotherapist is required.

Physiotherapist-Led Triage at a Rheumatology-Based Musculoskeletal Assessment Clinic: an 18-Month Service Evaluation of Activity and Outcomes.

OBJECTIVE: Physiotherapist-led musculoskeletal triage clinics are an effective and efficient means of managing patients presenting with musculoskeletal disorders in primary and secondary care. Data regarding the activity and outcomes of physiotherapist-led triage in hospital-based outpatient rheumatology clinics are scarce. Thus, the aim of this study was to undertake a service evaluation of activity and outcomes of a physiotherapist-led rheumatology-based Musculoskeletal Assessment Clinic (MAC). The primary objective was to quantify the proportion of patients independently managed by the clinical specialist physiotherapists (CSPs). METHODS: A retrospective service evaluation was undertaken of all patients who attended the Rheumatology MAC at St Vincent's University Hospital, Dublin (SVUH) between August 2012 and February 2014. The Clinical Audit Department of SVUH approved the study. Data were analyzed using descriptive statistics. RESULTS: Five hundred and eight patients attended the MAC: 76% were female and the mean age was 55 years and ranged between 18-91. Seventy-five percent of patients were independently managed by the CSP without needing to see a consultant rheumatologist, whereas 17% were referred to the rheumatology team. Eighty-seven percent of patients referred to the rheumatology team had rheumatological intervention (eg, injection, medical management, or multidisciplinary rehabilitation). A substantially higher proportion of patients with regional musculoskeletal pain and degenerative conditions were independently managed by the CSP compared with those who had rheumatological/inflammatory conditions. CONCLUSION: The majority of patients who attended the MAC were independently managed by the physiotherapists, suggesting that physiotherapist-led triage may be a useful and efficient means of managing a proportion of patients referred for a specialist rheumatological consultation.