Prevalence and perceptions of pain in people with haemophilia: A UK study.

INTRODUCTION: Joint bleeds in haemophilia cause destruction of articular structures, impaired function and pain. Up to 70% of people with haemophilia (PWH) report chronic pain. Little is known about the pain experiences in PWH in the UK. AIM: To identify prevalence and perceptions of pain among PWH living in the UK. METHODS: A cross-sectional, non-interventional survey study conducted among PWH (all severities). The survey incorporated elements from validated tools (EQ-5D; EQ-VAS) and was distributed via participating treatment centres. RESULTS: Five hundred and ninety-nine PWH responded, 91% aged > 18. 81% used factor prophylactically or on demand. More pain was reported by those treated on demand versus prophylaxis particularly in those who reported daily pain. 65% reported 'problem joints' based on individual impact rather than medically defined 'target joints', 2/3 reported multiple joint issues. The ankle was most commonly affected. 59% reported frequent pain, with 56% aware of pain constantly or most of the time and were more likely to report less favourable EQ-5D or EQ-VAS scores (p < .001). Pain frequency/awareness was consistent across all severities. Most discussed pain with care teams, 31% only when asked; 25% did not discuss it. Pain discussions resulted in physiotherapy referral (63%) analgesia prescription (48%), and a minority specialist pain referral (9%). Most felt well supported with regard to their pain, but 70% reported learning to live with it. CONCLUSION: Pain affects PWH of all ages and severities even in a well-resourced country significantly impacting quality of life. Clinicians must be more aware of chronic pain in PWH. Biopsychosocial approaches to pain assessment and management are recommended.

Pain interferes with daily activities, emotions and sleep in adults with severe, moderate and mild haemophilia: A national cross-sectional survey.

INTRODUCTION: Pain is a major issue in people with haemophilia (PwH). Few studies comprehensively assessed pain in PwH using a biopsychosocial framework and studies in mild PwH are lacking. AIM: To assess pain prevalence, pain interference and their relationship with health-related quality of life (HR-QoL) in male adults with haemophilia. METHODS: A survey was initiated by the Belgian national member organisation. Pain in the last 24 h, pain severity (BPI-PS) and pain interference (BPI-PI) scores were obtained with the Brief Pain Inventory short-form (BPI). HR-QoL was evaluated with the EQ-5D-3L, giving the health utility index (EQ-HUI). Associations between EQ-HUI, BPI-PS and BPI-PI were analysed using Pearson's correlation test. A multiple regression analysed the relationship between HR-QoL and BPI-PS, with age and haemophilia severity as confounding factors. RESULTS: Within 185 respondents (97, 31 and 57 respectively severe, moderate and mild PwH), 67% (118/177) reported pain. In severe, moderate and mild PwH, respectively 86% (79/92), 71% (22/31) and 32% (17/54) reported pain. Median [IQR] BPI-PS, BPI-PI and EQ-HUI scores were respectively 1.5 [.0; 4.0], 1.6 [.0; 3.6] and .81 [.69; 1.00]. PwH reported pain interference with general activity (56% (99/176)), psychosocial factors such as mood (53% (93/175)), and sleep (51% (90/177)). Moderate correlations were found between EQ-HUI, BPI-PS and BPI-PI. After adjusting for age and haemophilia severity, BPI-PS explained 14% of HR-QoL variance. CONCLUSIONS: Pain is a major issue amongst PwH, including people with mild haemophilia. Pain interferes with activities, emotions, sleep and HR-QoL, arguing for a comprehensive biopsychosocial approach of pain.

Discordance between joint pain and imagery severity in the ankle joint and contributors of lower limb activity limitations in adults with haemophilia: A cross-sectional study.

INTRODUCTION: People with haemophilia (PwH) suffer from knee and ankle joint pain, but the association with structural damage remains underexplored. They report activity limitations but it is unclear which factors contribute to lower limb activity limitations (LL-AL). AIMS: This study aimed (i) to analyse the association between ankle joint pain and structure and (ii) explore the contribution of haemophilia-related, individual and psychological factors to LL-AL in PwH. METHODS: This study included 104 moderate/severe PwH. Ankle pain intensity was assessed with a numeric rating scale and pain sensitivity with algometry (pressure pain threshold (PPTA )). Ankle structure was assessed with MRI (IPSG-MRI) and ultrasound (HEAD-US), joint health with the Haemophilia Joint Health Score (HJHS). The HAL-LOWCOM subscore evaluated LL-AL. A Spearman correlation analysed the correlation between ankle pain and structure. The contribution of haemophilia-related factors (joint health, overall pain (Brief Pain Inventory-Pain Severity (BPI-PS)), functional status (2-Minute-Walking-Distance, Timed Up and Go); individual factors (age, BMI) and psychological factors (fear and avoidance beliefs over physical activity (FABQ-PA) and work (FABQ-Work), anxiety and depression) to LL-AL was explored using a regression analysis. RESULTS: Only low correlations were found between ankle pain intensity and structure (IPSG-MRI, HEAD-US). PPTA was unrelated to structure. Altogether, HJHS, overall pain (BPI-PS), FABQ-Work and age explained 69% of HAL-LOWCOM variance, with 65% explained by the combination of HJHS and BPI-PS. CONCLUSION: No meaningful associations were found between ankle pain and structural damage, suggesting that other factors may contribute to PwH's ankle pain. In contrast, mainly haemophilia-related factors explained LL-AL variance.

ACTIVLIM-Hemo: A new self-reported, unidimensional and linear measure of activity limitations in persons with haemophilia.

INTRODUCTION: To assess activity limitations in people with haemophilia (PwH), the self-reported Haemophilia Activity List (HAL) is widely employed, despite several methodological limitations impacting the interpretation of categorical scores. Modern psychometric approaches avoid these limitations by using a probabilistic model, such as the Rasch model. The ACTIVLIM is a Rasch-built measurement of activity limitations previously validated in several clinical conditions like neuromuscular disorders. AIMS: This study sought to develop the ACTIVLIM-Hemo, meaning an ACTIVLIM scale version specifically adapted to assess daily activity limitations in adult PwH. METHODS: Daily activities were assessed as "impossible," "difficult" or "easy" by 114 PwH (median age of 44 years) with 63 of them reassessed after 12 days. The Rasch Rating Scale model was used to identify activities delineating a unidimensional and linear scale unbiased by demographic and clinical status. Concurrent validity was determined through correlation with the HAL sub-scores and sum score. RESULTS: The ACTIVLIM-Hemo included 22 pertinent activities, with difficulties independent of demographic and clinical conditions, allowing a reliable measure of activity limitations (PSI = .92) expressed on a linear and unidimensional scale in PwH (7%-100 % range, ceiling effect of 1/114) with excellent test-retest reliability (ICC = .978). Spearman rank correlations between ACTIVLIM-Hemo and HAL sub-scores ranged between .623 and .869. CONCLUSIONS: The ACTIVLIM-Hemo is an easy-to-administer, valid and reliable alternative to HAL in assessing activity limitations in PwH. Its invariant scale can be used across conditions and time to compare the functional status of PwH over a wide measurement range.

Joint status, pain and quality of life in elderly people with haemophilia: A case-control study.

INTRODUCTION: Elderly people with haemophilia (PwH) develop haemophilic arthropathy, pain, and reduced health-related quality of life (HR-QoL). The condition of elderly mild haemophilia patients have rarely been evaluated. This study aimed to compare joint status, pain, and HR-QoL between elderly with mild, moderate/severe haemophilia and healthy elderlies. METHODS: Knee/ankle abnormalities were assessed by ultrasound (HEAD-US) and physical examination (HJHS 2.1). Pain severity and pain interference were investigated using the Brief Pain Inventory. Pressure pain thresholds (PPTs) were obtained at knees/ankles and forehead. Functional limitations were evaluated using the 2-Minute-Walking-Test, Timed-Up-and-Go and HAL. The EQ-5D-5L questionnaire evaluated HR-QoL. Healthy controls (HCs) and elderly individuals with moderate/severe and mild haemophilia were compared using Kruskal-Wallis and Mann-Whitney U tests. RESULTS: From the 46 elderly PwH approached, 40 individuals (≥60 years) with haemophilia A/B (17 moderate/severe; 23 mild) and 20 age-matched HCs were recruited. Moderate/severe PwH displayed worse joint status, lower PPTs, and poorer HR-QoL than mild PwH and HCs (p-value = .010-<.001). HEAD-US abnormalities were observed in 100% of knees and 94% of ankles in moderate/severe PwH, versus 50% of knees and 61% of ankles in mild PwH. Pain was reported by 80% and 57% of moderate/severe and mild PwH, respectively. Low PPTs, functional limitations, and poor HR-QoL scores were likewise observed in some mild PwH, yet without significantly differing from HCs. CONCLUSION: This study highlights poor joint/functional status, pain, and HR-QoL outcomes in elderly with moderate/severe haemophilia. A few mild haemophilia subjects presented joint abnormalities, pain, functional limitations, and poor HR-QoL, without significantly differing from HCs. HIGHLIGHTS: Elderly individuals with mild haemophilia have not yet been extensively studied, whereas moderate/severe haemophilia individuals have proven to suffer from haemophilic arthropathy, pain, and poor health-related quality of life (HR-QoL). Using a case-control design, joint status, pain, and HR-QoL outcomes were examined in elderly haemophilia individuals and compared with those of healthy controls (HCs). Elderly moderate/severe haemophilia individuals exhibited worse joint status, increased joint pain sensitivity, and reduced HR-QoL compared with both mild haemophilia subjects and HCs. A subset of mild haemophilia subjects exhibited poor joint status, pain, and HR-QoL outcomes, without any differences noted when compared with HCs.

Psychophysical assessment of pain in adults with moderate and severe haemophilia: A cross-sectional study.

BACKGROUND: Joint pain is the hallmark of haemophilia; therefore it seems clinically rather a musculoskeletal than a bleeding disorder. Although joint pain in people with haemophilia (PwH) is a complex and multidimensional problem, pain assessment remains primarily focused on the structural evaluation of their joints. Whereas, only few data are available on the potential implication of psychophysical and psychological factors. OBJECTIVE: This study aimed to perform a psychophysical pain assessment including quantitative sensory testing (QST) and an evaluation of psychological factors in a large sample of PwH, to get insight into the individuals' pain system. METHODS: Ninety-nine adults (36.9 ± 13.5 years) with moderate/severe haemophilia A/B and 46 healthy controls filled in self-reported pain and psychological questionnaires and underwent a QST evaluation including static and dynamic tests. Static tests focused on the determination of thermal detection and pain thresholds and mechanical pressure pain thresholds. Dynamic tests evaluated pain facilitation and the efficacy of endogenous pain inhibition. Besides comparing PwH and healthy controls, between-subgroup differences were studied in PwH based on their pain distribution. RESULTS: The study revealed increased thermal and mechanical pain sensitivity and the presence of unhelpful psychological factors such as anxiety/depression in PwH. Among the subgroups, especially PwH with widespread pain showed altered somatosensory functioning. Enhanced pain facilitation and impaired efficacy of endogenous pain inhibition in PwH could not be observed. CONCLUSION: Altered somatosensory functioning and unhelpful psychological factors, appear to play an important role in the pathophysiology of pain in PwH, especially in PwH with widespread pain.

Barriers and facilitators to physical activity in cancer survivors with pain: a systematic review.

PURPOSE: Pain post-treatment is a debilitating symptom in the growing population of cancer survivors. While physical activity is an integral part of pain management, low levels of physical activity are often observed in this population. The aim of this systematic review is to gain insight into the barriers and facilitators to physical activity in cancer survivors afflicted with pain. METHODS: In December 2021, a systematic search was conducted using PubMed and Web of Science. All studies exploring barriers and/or facilitators to physical activity in cancer survivors with pain were included. The methodological quality of the evidence was appraised with the Mixed Methods Appraisal Tool (version 2018). RESULTS: Six articles were included. Current literature was limited and mostly focused on female breast cancer survivors. The identified barriers and facilitators could be categorized into six different domains: the logistical, symptoms, cognitive, clinical, social, and knowledge domain. The barrier of pain was reported as a barrier on its own that is closely linked to other barriers in this specific population. CONCLUSION: Barriers and facilitators to physical activity were categorized in six different domains. The barrier of pain distinguishes itself and brings along additional obstacles such as anxiety, fear, and avoidance behavior. Current evidence is limited and focuses mostly on female breast cancer survivors. Further research in larger cohorts representing various subsets of cancer survivors with pain is warranted, as well as studies that implement these insights in physical activity interventions.

Pain coping behaviour strategies in people with haemophilia: A systematic literature review.

INTRODUCTION: Despite the fact that joint bleeds (haemarthrosis) frequently occur in people with haemophilia (PwH) with invalidating arthropathies as result, the clinical pain experience has received only limited attention. A sudden increase in pain intensity can be linked to a bleed, but in most cases, no acute bleed is confirmed. Nevertheless, a patient's perception of an acute bleed as cause of the pain might impact the patients' behaviour in response to pain. It is therefore essential to gain more insight into pain coping strategies seen in PwH. AIM: This systematic review aims to identify the range of pain coping behaviour strategies used among PwH and the factors associated with pain coping behaviour. METHODS: This review was reported according to the Preferred Reporting Items for Systematic reviews and Meta-analyses guidelines (PRISMA). PubMed and Web of Science were systematically screened for relevant literature using keyword combinations related to adult PwH, pain and pain coping behaviour strategies. Risk of bias was assessed with the modified Newcastle-Ottowa Scale. RESULTS: Eleven full text articles (nine cross-sectional and two comparative studies) consisting of 1832 PwH met the inclusion criteria. Due to the heterogeneity of the study samples, quality of evaluation instruments and varying risk of bias, it was difficult to draw conclusions regarding the used pain coping behaviour strategies and associated factors. CONCLUSION: Literature on pain coping behaviour strategies and associated factors in PwH is still scarce and describes heterogenous results. Validated haemophilia-specific instruments are warranted to inventory pain coping behaviour in a standardized way.

Gaining more insight into ankle pain in haemophilia: A study exploring pain, structural and functional evaluation of the ankle joint.

INTRODUCTION: Ankle arthropathy is highly prevalent among people with haemophilia (PwH), even with prophylaxis, and leads to pain and disability. Mechanisms and consequences of painful symptoms related to ankle arthropathy have not been extensively studied. METHODS: A consecutive sample of 30 adult PwH was included (60 ankles). Ankle structure was assessed with magnetic resonance imaging (IPSG-MRI) and ultrasound (HEAD-US). The HJHS 2.1 assessed function of ankles and knees. Physical functioning was assessed with the Timed Up and Go test, the 2-Minute Walking Test and activity limitations with the HAL questionnaire. Health-related quality of life was evaluated using the EQ-5D-5L questionnaire. Overall pain severity was examined using the Brief Pain Inventory questionnaire and ankle pain intensity with a visual analogue scale. Pressure pain thresholds with an algometer assessed pain sensitivity. Spearman correlations were used to calculate interrelations between joint structure, function and pain. RESULTS: Twenty-five PwH (83%) reported ≥1 painful joint, with 67% reporting the ankle as most painful joint. MRI-confirmed abnormalities were seen in 76% of talocrural and 55% of subtalar joints. HEAD-US abnormalities were seen in 93% of the ankles. A large variation was seen in pain sensitivity at the ankle. While moderate to high correlations were observed between ankle structure and HJHS, no meaningful correlations were found between MRI-scores and pain intensity or sensitivity. CONCLUSIONS: Structural joint damage is present in many ankles but is not related to pain in PwH. Further studies should consider somatosensory nervous system dysfunction in PwH as contributing factor to painful ankle arthropathy.

Evidence for alterations to dynamic quantitative sensory tests in patients with chronic temporomandibular myalgia: A systematic review of observational studies with meta-analysis.

BACKGROUND: Conflicting results exist between somatosensory profiles of patients with temporomandibular myalgia (TMDm). The objective of this review was to examine whether adults with TMDm show altered responses to dynamic quantitative sensory tests compared with healthy controls. METHODS: We searched five electronic databases for studies, excluding those without suitable controls or where TMDm was associated with confounding non-musculoskeletal disorders. Risk of bias was assessed with the SIGN case-control study checklist. Findings were structured around dynamic quantitative sensory tests and their localization. Where possible, we performed meta-analysis with a random inverse variance model to compare patients with TMDm and healthy controls. Statistical heterogeneity was estimated with Chi² test and inconsistency index, I². RESULTS: We extracted data from 23 studies comprising 1284 adults with chronic TMDm and 2791 healthy controls. Risk of bias was assessed as high for 20 studies. Mechanical temporal summation, the most studied phenomenon (14 studies), is increased in the upper limb of patients with TMDm (SMD = 0.43; 95% CI: .11 to .75; p = .009) but not in the jaw area (p = .09) or in the cervical area (p = .29). Very little evidence for altered thermal temporal summation (five studies), conditioned pain modulation (seven studies), exercise-induced hypoalgesia (two studies), placebo analgesia (two studies), stress-induced hypoalgesia (one study) and offset analgesia (one study) was found. DISCUSSION: A major limitation of this review was the risk of bias of included studies. Future studies would benefit from following methodological guidelines and consideration of confounding factors.

Sensorimotor performance in acute-subacute non-specific neck pain: a non-randomized prospective clinical trial with intervention.

BACKGROUND: The assessment of cervical spine kinematic axial rotation performance is of great importance in the context of the study of neck sensorimotor control. However, studies addressing the influence of the level of provocation of spinal pain and the potential benefit of passive manual therapy mobilizations in patients with acute-subacute non-specific neck pain are lacking. METHODS: A non-randomized prospective clinical trial with an intervention design was conducted. We investigated: (1) the test-retest reliability of kinematic variables during a fast axial head rotation task standardized with the DidRen laser test device in 42 Healthy pain-free Control Participants (HCP) (24.3 years ±6.8); (2) the differences in kinematic variables between HCP and 38 patients with Acute-subacute Non-Specific neck Pain (ANSP) assigned to two different groups according to whether their pain was localized in the upper or lower spine (46.2 years ±16.3); and (3) the effect of passive manual therapy mobilizations on kinematic variables of the neck during fast axial head rotation. RESULTS: (1) Intra-class correlation coefficients ranged from moderate (0.57 (0.06-0.80)) to excellent (0.96 (0.91-0.98)). (2) Kinematic performance during fast axial rotations of the head was significantly altered in ANSP compared to HCP (age-adjusted) for one variable: the time between peaks of acceleration and deceleration (p<0.019). No significant difference was observed between ANSP with upper vs lower spinal pain localization. (3) After the intervention, there was a significant effect on several kinematic variables, e.g., ANSP improved peak speed (p<0.007) and performance of the DidRen laser test (p<0.001), with effect sizes ranging from small to medium. CONCLUSION: (1) The DidRen laser test is reliable. (2) A significant reduction in time between acceleration and deceleration peaks was observed in ANSP compared to HCP, but with no significant effect of spinal pain location on kinematic variables was found. (3) We found that neck pain decreased after passive manual therapy mobilizations with improvements of several kinematic variables. TRIAL REGISTRATION: Registration Number: NCT04407637.

Digital pain drawings are a useful and reliable tool for assessing patients with temporomandibular disorders.

BACKGROUND: Temporomandibular disorders (TMD) are characterised by complex symptomatology and their assessment can be enhanced using pain drawings (PD). OBJECTIVES: To evaluate the location and extent of pain in people TMD using digital PD, and to explore their association with clinical features. Reliability of pain extent and pain location using PD was also assessed. METHODS: Forty volunteers with TMD completed two consecutive digital PDs. Clinical features were captured from self-reported questionnaire. Additionally, secondary hyperalgesia was measured using the pressure pain threshold (PPT). The correlation between pain extent and clinical features was investigated using Spearman rank correlation coefficients. Reliability of pain extent was evaluated using intraclass correlation coefficient (ICC) and Bland-Altman plots. The Jaccard index was computed to assess the reliability of pain location. RESULTS: Analysis of the PDs indicated that people with TMD commonly experience pain in other body regions including the neck, the shoulder and the low back. Except for PPT and pain catastrophising, all other clinical features were significantly correlated with pain extent. The ICCs of pain extent for all body charts were very high (ICCs 95% CI from 0.73 to 0.96), and Bland-Altman plots showed mean biases close to zero with narrow limits of agreement. The reliability of pain location was also supported by Jaccard index mean scores above 0.68. CONCLUSIONS: People with TMD showed widespread pain, and pain extent was associated with pain intensity, neck and headache-related disability, depression, anxiety, hyperventilation and central sensitivity. The reliability of measuring pain extent and pain location was confirmed.

Processing of Laser-Evoked Potentials in Patients with Chronic Whiplash-Associated Disorders, Chronic Fatigue Syndrome, and Healthy Controls: A Case-Control Study.

OBJECTIVE: Laser-evoked potentials (LEPs) are among the reliable neurophysiological tools to investigate patients with neuropathic pain, as they can provide an objective account of the functional status of thermo-nociceptive pathways. The goal of this study was to explore the functioning of the nociceptive afferent pathways by examining LEPs in patients with chronic whiplash-associated disorders (cWAD), patients with chronic fatigue syndrome (CFS), and healthy controls (HCs). DESIGN: Case-control study. SETTING: A single medical center in Belgium. SUBJECTS: The LEPs of 21 patients with cWAD, 19 patients with CFS, and 18 HCs were analyzed in this study. METHODS: All participants received brief nociceptive CO2 laser stimuli applied to the dorsum of the left hand and left foot while brain activity was recorded with a 32-channel electroencephalogram (EEG). LEP signals and transient power modulations were compared between patient groups and HCs. RESULTS: No between-group differences were found for stimulus intensity, which was supraliminal for Aδ fibers. The amplitudes and latencies of LEP wave components N1, N2, and P2 in patients with cWAD and CFS were statistically similar to those of HCs. There were no significant differences between the time-frequency maps of EEG oscillation amplitude between HCs and both patient populations. CONCLUSIONS: EEG responses of heat-sensitive Aδ fibers in patients with cWAD and CFS revealed no significant differences from the responses of HCs. These findings thus do not support a state of generalized central nervous system hyperexcitability in those patients.

Does Pain Neuroscience Education and Cognition-Targeted Motor Control Training Improve Cervical Motor Output? Secondary Analysis of a Randomized Clinical Trial.

BACKGROUND: In the context of interventions aimed at reducing pain, disability, and maladaptive pain cognitions in chronic neck pain, it is hypothesized that patients who have greater symptom reduction possibly also demonstrate greater improvement in cervical motor output. Therefore, the aim of this study was to examine the effect of pain neuroscience education plus cognition-targeted motor control training on cervical motor output. METHODS: Impairments in cervical motor output were measured in 64 subjects with chronic neck pain using standardized tests. Cervical muscle strength, cervical mobility, balance, and cervical neuromuscular control were derived. To assess the differences between groups in response to treatment, a random-intercept linear mixed-models analysis, applying a diagonal covariance matrix, was used. RESULTS: A significant treatment × time interaction effect was found for neuromuscular control of the deep cervical flexors, favoring the experimental treatment at 3 months' follow-up (mean group difference: 1.982; 95% confidence interval 0.779, 3.185; large effect size d = 0.82). Significant main effects of time were found for the neuromuscular capacity of scapulothoracic muscles and for cervical mobility. No significant effects were found for balance, cervical muscle strength, or endurance of cervical flexors. CONCLUSION: Pain neuroscience education combined with cognition-targeted motor control training is not more effective than biomedically focused education and exercise therapy for improving cervical motor output in people with chronic neck pain. Our findings question the relative importance of factors such as pain, disability, and maladaptive pain cognitions on cervical motor output and the need to address it in treatment.

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.

Association Between Symptoms of Central Sensitization and Cognitive Behavioral Factors in People With Chronic Nonspecific Low Back Pain: A Cross-sectional Study.

OBJECTIVE: The objective of this cross-sectional study was to analyze the relationship between symptoms of central sensitization (CS) and important cognitive behavioral and psychosocial factors in a sample of patients with chronic nonspecific low back pain. METHODS: Participants with chronic nonspecific low back pain for at least 3 months were included in the study. They completed several questionnaires and a functional test. Pearson's correlation was used to analyze associations between symptoms of CS and pain behavior, functioning, pain, pain catastrophizing, kinesiophobia, and illness perceptions. Additionally, a between-group analysis was performed to compare patients with and without clinically relevant symptoms of CS. RESULTS: Data from 38 participants were analyzed. Significant associations were found between symptoms of CS and all other outcomes, especially current pain (r = 0.510, P = .001), mean pain during the past 7 days (r = 0.505, P = .001), and pain catastrophizing (r = 0.518, P = .001). Patients with clinically relevant symptoms of CS scored significantly worse on all outcomes compared with persons without relevant symptoms of CS, except on functioning (P = .128). CONCLUSIONS: Symptoms of CS were significantly associated with psychosocial and cognitive behavioral factors. Patients exhibiting a clinically relevant degree of symptoms of CS scored significantly worse on most outcomes, compared with the subgroup of the sample with fewer symptoms of CS.

Illness Perceptions Explain the Variance in Functional Disability, but Not Habitual Physical Activity, in Patients With Chronic Low Back Pain: A Cross-Sectional Study.

INTRODUCTION: Although the importance of psychosocial factors has been highlighted in many studies in patients with chronic low back pain (CLBP), there is a lack of research examining the role of illness perceptions in explaining functional disability and physical activity in patients with CLBP. AIM: The aim of the study was to explore the value of illness perceptions in explaining functional disability and physical activity in patients with CLBP. METHODS: Eighty-four participants with CLBP (of > 3 months' duration) completed a battery of questionnaires investigating psychosocial factors (Pain Catastrophizing Scale [PCS], Illness Perceptions Questionnaire Revised [IPQ-R], and 36-Item Short Form mental health scale [SF-36_MH]) and perceived pain intensity (visual analog scale [VAS]), as well as the Oswestry Disability Index (ODI) and Baecke questionnaire. The latter 2 were entered separately as dependent variables in a regression analysis. RESULTS: The combined variables (VAS, PCS, SF-36_MH, IPQ-R) accounted for 62% of the variance in functional disability (ODI). Adding the results of the IPQ-R to the scores of the other 3 variables (VAS, PCS, SF-36_MH) significantly increased the explained variance of ODI scores in CLBP patients, yielding 18% additional information (P < 0.01). Only 5% of the variance in the Baecke questionnaire was explained by combining the 4 variables. None of the single variables alone made a significant contribution to R². CONCLUSIONS: Illness perceptions are an important factor for explaining functional disability, but not for explaining habitual physical activity in CLBP patients.

Abnormal Pain Response to Visual Feedback During Cervical Movements in Chronic Whiplash: An Experimental Study.

BACKGROUND: Whiplash-associated disorders (WAD) are a debilitating condition. In chronic WAD, sensorimotor incongruence exacerbates symptoms. Sensorimotor incongruence occurs when somatosensory input and predicted motor output are in conflict, which can trigger pain. On the other hand, there is evidence that visual feedback can decrease pain in certain chronic pain conditions. Therefore, the aim of this study was to examine the effect of visual feedback and sensorimotor incongruence on pain thresholds in chronic WAD. METHODS: Sixty-four participants (healthy controls and patients with chronic WAD) were subjected to six experimental conditions. Participants watched correct real-time or modified visual feedback of the neck or hand (without movement as well as during repetitive neck lateroflexion). Sensorimotor incongruence was induced by manipulating visual feedback. Pressure pain thresholds were measured at baseline and during each condition. RESULTS: Marked between-group differences were observed. Visual feedback of the neck-correct or modified-did not influence pain thresholds in chronic WAD. In contrast, healthy controls had significantly higher pain thresholds when provided with the correct or modified visual feedback. When a movement of the neck was added during visual feedback, patients with chronic WAD showed no significant difference in pain thresholds, while an increase in pain thresholds was found in the healthy control group. CONCLUSION: In contrast to the healthy controls, visual feedback and sensorimotor incongruence did not alter pain thresholds in patients with chronic WAD. These findings suggest an abnormal pain response to visual feedback and somatosensory incongruence as well as failing mechanisms of pain inhibition in chronic WAD.

Cervico-cephalalgiaphobia: a subtype of phobia in patients with cervicogenic headache and neck pain? A pilot study.

OBJECTIVES: The term 'cephalalgiaphobia' was introduced in the mid-1980s and defined as fear of migraine (attacks). We hypothesized that a specific subtype of cephalalgiaphobia affects patients with cervicogenic headache (CEH). This study aimed to: (1) define the term 'cervico-cephalalgiaphobia'; (2) develop a set of indicators for phobia relevant to patients with CEH; and (3) apply this set to a practice test in order to estimate the frequency of cervico-cephalalgiaphobia in the Dutch primary care practice of manual physical therapy. METHODS: A systematic approach was used to develop a definition and potential indicators for cervico-cephalalgiaphobia. An expert group appraised the definition and the set of indicators (score per indicator: never; sometimes; often/always). An invitation to participate in the practice test was sent to Dutch manual physical therapy practices (n = 56) representing 134 manual physical therapists (MPTs). The cut-off point for percentages of scores for coverage of the indicators was set at ≥ 60%. RESULTS: The expert group agreed with the proposed definition of cervico-cephalalgiaphobia. A set of eight indicators for cervico-cephalalgiaphobia was selected from 10 initial indicators. Thirty-six MPTs provided data from 46 patients diagnosed with CEH. The coverage of 'often/always' was substantial for the indicators, 'Short-term positive results in previous manual physical therapeutic treatment', 'Shorter interval between treatment sessions', 'Fear of "locked facet joints" of the neck', 'More frequent manipulation', and 'Fear of increase in headaches'. Coverage was also substantial for 'never' regarding 'Long-term positive results in previous manual physical therapeutic treatment'. 'Confirmation of "locked facet joints" of the cervical spine by MPT as a cause for increase of CEH' scored 'often/always' in all patients. Coverage for 'Increased use of medication with insufficient effect' was substantial, scoring as 'sometimes' in 39 (84.8%) patients. DISCUSSION: Cervico-cephalalgiaphobia was defined and a set of eight indicators formulated based on the literature and clinical expertise. The practice test provides valuable information on the frequency of indicators for cervico-cephalalgiaphobia in the Dutch manual physical therapy practice, suggesting that cervico-cephalalgiaphobia is common in patients with CEH.

Prevalence, Incidence, Localization, and Pathophysiology of Myofascial Trigger Points in Patients With Spinal Pain: A Systematic Literature Review.

OBJECTIVE: A systematic review was performed to evaluate the existing evidence related to the prevalence, incidence, localization, and pathophysiology of myofascial trigger points (MTrPs) in patients with spinal (back and neck) pain. METHODS: A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed in 2 electronic databases (PubMed and Web of Science) using predefined keywords regarding MTrPs and spinal pain. A "PICOS" questionnaire was used to set up the search strategies and inclusion criteria. Full-text reports concerning MTrPs in patients with back or neck pain, which described their prevalence, incidence, location, or underlying physiopathology were included and screened for methodological quality by 3 independent researchers. Each study was assessed for risk of bias using a checklist derived from the Web site of the Dutch Cochrane Centre. RESULTS: Fourteen articles were retrieved for quality assessment and data extraction. Studies reporting the incidence of MTrPs in patients with spinal pain were lacking. Within spinal pain, patients with neck pain were found to have the highest prevalence rates of MTrPs. The trapezius descendens, levator scapulae, and suboccipitales muscles were the most prevalent locations for active MTrPs in patients with neck pain. Latent MTrPs were present in asymptomatic people, but no significant differences were found in the prevalence rate of latent MTrPs between patients with spinal (neck) pain and healthy controls. The only study investigating prevalence of MTrPs in different localizations of the same muscle reported no significant differences in prevalence between active and latent MTrPs within the trapezius descendens muscle. Studies examining pathophysiological mechanisms underlying MTrPs demonstrated an acidic environment, high concentration of algogenic/inflammatory substances, stiffer muscle tissue, retrograde diastolic blood flows, spontaneous muscle activity at rest, and loss of muscle contractibility in muscles with MTrPs. Altered central processing was also found to play a role in the development of MTrPs. CONCLUSIONS: Myofascial trigger points are a prevalent clinical entity, especially in patients with neck pain. Evidence was not found to support or deny the role of MTrPs in other spinal pain. Compelling evidence supports local mechanisms underlying MTrPs. Future research should unravel the relevance of central mechanisms and investigate the incidence of MTrPs in patients with spinal pain.