[Contribution of physical and rehabilitation medicine to primary care medicine]. / Apport de la médecine physique et de réadaptation à la médecine de premier recours.

Physical and rehabilitation medicine (PRM) is an independent medical specialty, little known in Switzerland. This specialty, strongly linked to the holistic approach of the International Classification of Functioning, will be increasingly solicited by the epidemiology of disability and the imperatives of "ageing better". Its skills in prescribing human and material resources for rehabilitation provide added value in terms of loss of autonomy. Based on a biopsychosocial model, PRM has a high role to play in prevention and primary healthcare, as well as in the management and prevention of the consequences of functionally limiting diseases. There are, however, financial (pricing) and demographic (lack of representation) obstacles to effective action on behalf of the population and the healthcare system.

La médecine physique et de réadaptation (MPR), discipline indépendante, est peu connue en Suisse. Cette spécialité, liée à l'approche holistique de la classification internationale du fonctionnement, sera de plus en plus sollicitée par l'épidémiologie du handicap et les impératifs du « vieillir mieux ¼. Ses compétences de prescription des moyens humains et matériels en réadaptation apportent une plus-value sur la perte d'autonomie. Basée sur un modèle biopsychosocial, la MPR trouve sa place dans la prévention et les soins de santé primaires ainsi que dans la prise en charge et la prévention des conséquences des maladies induisant une limitation fonctionnelle. Il existe toutefois des obstacles financiers (tarification) et démographiques (insuffisance de représentation) pour une action efficace au service de la population et du système de santé.

Changes in spinal motor behaviour are associated with reduction in disability in chronic low back pain: A longitudinal cohort study with 1-year follow-up.

BACKGROUND: The need to improve spinal motor behaviour in chronic low back pain (CLBP) rehabilitation remains unclear. The objective of this study was to test if changes in spinal motor behaviour were associated with changes in disability after an interdisciplinary rehabilitation program (IRP) in patients with CLBP. METHODS: Seventy-one patients with CLBP participating in an IRP were included. Spinal motor behaviour was assessed with biomechanical (lumbar angular amplitude and velocity, erector spinae muscle activity and duration of the task), cognitive-emotional (task-specific fear [PRF]) and pain-related (movement-evoked pain [MEP]) measures during a lifting task before and after the IRP. Disability was measured before and after the IRP, and at 3-month and 1-year follow-ups. RESULTS: After adjusting for confounders, changes in disability were significantly associated with MEP changes (ß adj. = 0.49, p < 0.001) and PRF changes (ß adj. = 0.36, p = 0.008), but not with changes in any of the biomechanical measures. MEP at the end of IRP was also associated with disability at 3 months (ß adj. = 0.37, p = 0.001) and 1 year (ß adj. = 0.42, p = 0.01). Biomechanical measures at the end of the IRP were not associated with disability, except for the duration of the task that was significantly associated with reduction of disability at 3 months (ß non-adj = 0.5, p < 0.001). CONCLUSIONS: Pain-related and cognitive-emotional measures of spinal motor behaviour were associated with reduction in disability following an IRP. Future research is needed to further investigate causal relationships between spinal motor behaviour and disability. SIGNIFICANCE STATEMENT: This study supports a multidimensional understanding and analysis of spinal motor behaviour, integrating the cognitive-emotional, pain-related and biomechanical domains. It also supports the consideration of spinal motor behaviour as a potentially important treatment target in chronic low back pain management. Moreover, it suggests that reducing movement-evoked pain and task-specific fear may have more influence on disability than changing lumbar amplitude, lumbar angular velocity or erector muscle activity, which may have important implications for rehabilitation.

Clinical Applications of Virtual Reality in Musculoskeletal Rehabilitation: A Scoping Review.

(1) Background: VR is based on a virtual world that creates sounds effects and videos that replace the real environment. Arising literature shows VR efficacy in the field of neurological rehabilitation (NR) and that its use is also taking a place in musculoskeletal rehabilitation (MSR), as a treatment of various disorders that cause disability and chronic pain. (2) Aim: We discuss the role of VR in MSR, presenting its use and development on acute and chronic musculoskeletal disorders, based on the most recent literature. (3) Design and Methods: Literature searches were conducted in the databases Pubmed and Medline up to 30 September 2023. The PRISMA-Scr Checklist was followed. (4) Results: A total of 51 records were included. The analysed studies were conducted within a variety of populations, musculoskeletal disorders, settings, and VR technologies. Only a few studies could statistically affirm the efficacy of VR in MSR, as mentioned for the rehabilitation of the upper limb. Nevertheless, the observed trend is an improvement of the global perceived effect compared to traditional rehabilitation. (5) Conclusion: VR allows for the personalisation of treatment with an adaptable treatment platform, which may improve the participation of the patient and increase acceptability and adherence to long-term rehabilitation programs. We provide recommendations and suggestions for future research and use of VR in musculoskeletal rehabilitation.

Short-term effects on heart rate variability of occipito-mastoid suture normalization in healthy subjects.

Occipito-mastoid structure normalization (OMSN) is an osteopathic manipulative treatment aimed at reducing tension around the jugular foramen, where cranial nerves IX, X, and XI exit the skull. The purpose of this study was to observe how heart rate variability (HRV), a marker of autonomic cardiac regulation, was modulated after an OMSN vs. a sham technique (SHAM). Pre- and post-intervention HRV was analyzed in two randomly chosen groups of 15 participants (OMSN vs. SHAM group). HRV was collected in the supine position 5 min before and 5 min after a 10-min application of either OMSN or SHAM. The time and group effect was analyzed using a two-way ANOVA. Independently from group intervention, a significant time effect induced increased HRV. No group effect differences were observed. Multiple comparisons for time and group interaction showed that the root mean square of successive differences (RMSSD), a vagally mediated HRV variable, increased to a greater extent for the OMSN group (p = 0.03) than for the SHAM group. However, both OMSN and SHAM techniques had a significant effect on HRV. Compared to a SHAM technique, OMSN had a significant effect on HRV vagally related metric RMSSD in the short term. We conclude that 10 min of OMSN may be used to induce a short-term influence on parasympathetic autonomic nervous system modulations.

Simple clinical tools improve ability-to-work predictions for individuals 3-24 months after upper limb injury.

BACKGROUND: Despite numerous previous studies, predicting the ability to work (ATW) after an upper limb injury (ULI) remains difficult for those still not working 3-24 months after their initial injury. OBJECTIVES: We aimed to identify simple prognostic characteristics that were associated with the long-term ATW for individuals who remained unable to work several months after the accident that caused their ULI. METHODS: A single-center prospective observational study in a rehabilitation center in the French-speaking part of Switzerland. We included participants who were 18-60 years old, still unable to work because of persistent pain/disability 3-24 months after an ULI, and who were referred to our rehabilitation center for a 1-month intensive interdisciplinary treatment. Data were collected on personal characteristics, body function/structure variables, activity limitations/participation restrictions, and environmental factors. Participants' evolution during rehabilitation was assessed using functional tests/questionnaires and the 7-level self-reported Patient's Global Impression of Change (PGIC) assessment at discharge. Participant outcomes after 1 year were categorized as either able (ATW>0%) or unable (ATW=0%) to work. The best prognostic characteristics were selected by logistic regression analysis. RESULTS: Among the 317 participants, 202 (64%) had an ATW>0% at 1 year. A grip strength ≥16 kg (Jamar Hand Dynamometer score - affected side) and "(I) do not take pain medicine" were independent predictors. Overall, 96% (26/27) of participants with these 2 characteristics had an ATW>0% at 1 year. The simultaneous absence of these characteristics predicted an unfavorable prognosis in 50% (59/119) of participants. For those who also had a positive PGIC score then 100% (25/25) of participants with these 3 characteristics had an ATW>0%; for those without, only 42% (19/45) had an ATW>0%. CONCLUSIONS: Grip strength (≥16 kg) and not taking pain medicine are favorable prognostic factors for an ATW after an ULI. Their absence is associated with a poor ATW prognosis for half of people with ULI and should alert caregivers to risk of long-term absenteeism ("red flags"). Including data from a PGIC further improves the ATW prediction. We recommend that these 3 criteria be systematically evaluated.

Development and Validation of Short Forms of the Pain Catastrophizing Scale (F-PCS-5) and Tampa Scale for Kinesiophobia (F-TSK-6) in Musculoskeletal Chronic Pain Patients.

Purpose: Chronic pain is a complex phenomenon. Understanding its multiple dimensions requires the use of a combination of several patient-reported outcome measures (PROMs). However, completing multiple PROMs is time-consuming and can be a burden for patients. The objective of our study was to simultaneously reduce the French versions of the Pain Catastrophizing Scale (PCS) and Tampa Scale for Kinesiophobia (TSK) questionnaires to enable their use in an ambulatory and clinical settings. Patients and Methods: We conducted a clinical study between May 2014 and August 2020 in our rehabilitation center. 1428 chronic musculoskeletal pain patients (CMSP) were included. The originality of our approach is that the reduction method included qualitative as well as quantitative analyses. The study was divided into two parts: 1) reduction of the questionnaires (n=1363) based on internal consistency (item-to-total correlation), principal component analysis (item loadings), Rasch analysis (infit/outfit), floor and ceiling effect (quantitative analyses) and expert judgment of items (qualitative analysis), and 2) validation of the reduced questionnaires (n=65), including test-retest reliability (intraclass correlation coefficient [ICC]), homogeneity (Cronbach α), criterion validity (Pearson correlation [r] with the long-version score), determination of the pathological cutoff and Minimal Clinically Important Difference (MCID). The two full-length questionnaires include 30 items in total. Results: The reduction resulted in a 5-item PCS (score 0-20) and 6-item TSK (score 0-24). Psychometric properties of the reduced questionnaires were all acceptable as compared with other version (α=0.89 and 0.71, ICC=0.75 and 0.60, r=0.86 and 0.70, MCID=2 and 2 for PCS and TSK, respectively) while keeping the structure and coherence of the long versions. Conclusion: The two reduced versions of the PCS and TSK can be used in CMSP patient. As their administration only requires a few minutes, they can be implemented in outpatient consultation as well as in clinical settings.

Reduction in pain-related fear is not associated with improvement in spinal biomechanics but with decrease in movement-evoked pain in patients with chronic low back pain.

BACKGROUND AND AIMS: While a causal relationship between pain-related fear and spinal movement avoidance in patients with chronic low back pain (CLBP) has frequently been postulated, evidence supporting this relationship is limited. This study aimed to test if decreases in pain-related fear or catastrophizing were associated with improvements in spinal biomechanics, accounting for possible changes in movement-evoked pain. METHODS: Sixty-two patients with CLBP were assessed before and after an interdisciplinary rehabilitation program (IRP). Pain-related fear was assessed with general and task-specific measures. Lower and upper lumbar angular amplitude and velocity as well as paraspinal muscle activity were recorded during five daily-life tasks to evaluate spinal biomechanics. Relationships were tested with multivariable linear regression analyses. RESULTS: The large decreases in pain-related fear and catastrophizing following the IRP were scarcely and inconsistently associated with changes in spinal biomechanics (< 3% of the models reported a statistically significant association). Results remained comparable for activities inducing more or less fear, for specific or general measures of pain-related fear, and for analyses performed on the entire population or limited to subgroups of patients with higher levels of task-specific fear. In contrast, reductions in task-specific pain-related fear were significantly associated with decreases in movement-evoked pain in all tasks (r = 0.26-0.62, p ≤ 0.02). CONCLUSION: This study does not support an association between pain-related fear and spinal movement avoidance. However, it provides evidence supporting a direct relationship between decreased pain-related fear and decreased movement-evoked pain, possibly explaining some mechanisms of the rehabilitation programs.

Short term high-intensity interval training in patients scheduled for major abdominal surgery increases aerobic fitness.

BACKGROUND: Prehabilitation may improve postoperative clinical outcomes among patients undergoing major abdominal surgery. This study evaluated the potential effects of a high-intensity interval training (HIIT) program performed before major abdominal surgery on patients' cardiorespiratory fitness and functional ability (secondary outcomes of pilot trial NCT02953119). METHODS: Patients were included before surgery to engage in a low-volume HIIT program with 3 sessions per week for 3 weeks. Cardiopulmonary exercise and 6-min walk (6MWT) testing were performed pre- and post-prehabilitation. RESULTS: Fourteen patients completed an average of 8.6 ± 2.2 (mean ± SD) sessions during a period of 27.9 ± 6.1 days. After the program, [Formula: see text]O2 peak (+ 2.4 ml min-1 kg-1, 95% CI 0.8-3.9, p = 0.006), maximal aerobic power (+ 16.8 W, 95% CI 8.2-25.3, p = 0.001), [Formula: see text]O2 at anaerobic threshold (+ 1.2 ml min-1 kg-1, 95%CI 0.4-2.1, p = 0.009) and power at anaerobic threshold (+ 12.4 W, 95%CI 4.8-20, p = 0.004) were improved. These changes were not accompanied by improved functional capacity (6MWT: + 2.6 m, 95% CI (- 19.6) to 24.8, p = 0.800). CONCLUSION: A short low-volume HIIT program increases cardiorespiratory fitness but not walking capacity in patients scheduled for major abdominal surgery. These results need to be confirmed by larger studies.

Cognitive assessment scale for stroke patients (CASP): A multicentric validation study.

BACKGROUND: The Mini Mental State Examination and Montreal Cognitive Assessment are commonly used as short screening batteries for assessing cognitive impairment after stroke. However, aphasia or hemispatial neglect may interfere with the results. For this reason, we developed the Cognitive Assessment scale for Stroke Patients (CASP), which takes these conditions into consideration and previously demonstrated its superiority over these scales in terms of feasibility. OBJECTIVES: Our goal was to verify the psychometric properties of the (original) French version of the CASP. METHODS: We included 201 patients with a recent first hemispheric stroke and 50 controls. Stroke patients were examined 4 times (visit 1 [V1] to visit 4 [V4]) in the subacute post-stroke phase. The structural validity of the CASP was studied by principal factorial analysis, convergent validity by comparison with several variables including a comprehensive neuropsychological assessment, divergent validity by comparison with the total score between stroke patients and controls, and sub-scores between right and left stroke. Internal consistency, reproducibility and sensitivity to change were assessed. We propose the Minimal Clinically Important Difference (MCID) value and a pathological threshold as well as a threshold to predict cognitive change between V1 and V4. RESULTS: Of the 201 participants included (63% male; mean [SD] age 63 [13] years), CASP data were available for 199/150/133/93 at V1/V2/V3/V4, respectively. CASP has a one-dimensional structure. The hypotheses of convergent/divergent validities were confirmed. Internal consistency was good and reliability excellent. Responsiveness was small to moderate, but the MCID could still be estimated. We discuss the choice of a pathological threshold and a predictive threshold of V1 over V4. CONCLUSIONS: CASP has good psychometric properties for screening cognitive impairment in the subacute post-stroke phase, which is consistent with its Italian and Korean versions. It can be used for patients with severe motor aphasia or left hemispatial neglect but not in case of severe oral comprehension or visual impairment.

Feasibility of a prehabilitation program before major abdominal surgery: a pilot prospective study.

OBJECTIVE: To assess the feasibility of a prehabilitation program and its effects on physical performance and outcomes after major abdominal surgery. METHODS: In this prospective pilot study, patients underwent prehabilitation involving three training sessions per week for 3 weeks preoperatively. The feasibility of delivering the intervention was assessed based on recruitment and adherence to the program. Its impacts on fitness (oxygen uptake (VO2)) and physical performance (Timed Up and Go Test, 6-Minute Walk Test) were evaluated. RESULTS: From May 2017 to January 2020, 980 patients were identified and 44 (4.5%) were invited to participate. The main obstacles to patient recruitment were insufficient time (<3 weeks) prior to scheduled surgery (n = 276, 28%) and screening failure (n = 312, 32%). Of the 44 patients, 24 (55%) declined to participate, and 20 (23%) were included. Of these, six (30%) were not adherent to the program. Among the remaining 14 patients, VO2 at ventilatory threshold significantly increased from 9.7 to 10.9 mL/min/kg. No significant difference in physical performance was observed before and after prehabilitation. CONCLUSION: Although prehabilitation seemed to have positive effects on exercise capacity, logistic and patient-related difficulties were encountered. The program is not feasible in its current form for all-comers.

Are patients with hypermobile Ehlers-Danlos syndrome or hypermobility spectrum disorder so different?

Diagnosing hypermobile Ehlers-Danlos syndrome (hEDS) remains challenging, despite new 2017 criteria. Patients not fulfilling these criteria are considered to have hypermobile spectrum disorder (HSD). Our first aim was to evaluate whether patients hEDS were more severely affected and had higher prevalence of extra-articular manifestations than HSD. Second aim was to compare their outcome after coordinated physical therapy. Patients fulfilling hEDS/HSD criteria were included in this real-life prospective cohort (November 2017/April 2019). They completed a 16-item Clinical Severity Score (CSS-16). We recorded bone involvement, neuropathic pain (DN4) and symptoms of mast cell disorders (MCAS) as extra-articular manifestations. After a standardized initial evaluation (T0), all patients were offered the same coordinated physical therapy, were followed-up at 6 months (T1) and at least 1 year later (T2), and were asked whether or not their condition had subjectively improved at T2. We included 97 patients (61 hEDS, 36 HSD). Median age was 40 (range 18-73); 92.7% were females. Three items from CSS-16 (pain, motricity problems, and bleeding) were significantly more severe with hEDS than HSD. Bone fragility, neuropathic pain and MCAS were equally prevalent. At T2 (20 months [range 18-26]) 54% of patients reported improvement (no difference between groups). On multivariable analysis, only family history of hypermobility predicted (favorable) outcome (p = 0.01). hEDS and HDS patients showed similar disease severity score except for pain, motricity problems and bleeding, and similar spectrum of extra-articular manifestations. Long-term improvement was observed in > 50% of patients in both groups. These results add weight to a clinical pragmatic proposition to consider hEDS/HSD as a single entity that requires the same treatments.

[Plantar fasciitis: update 2021]. / Aponévropathie plantaire : mise au point 2021.

Plantar heel pain affects 4 to 9% of the population and is a common reason for consultation. Plantar fasciitis is the most frequent cause. Its diagnosis is essentially clinical, possibly supported initially by combination of X-ray/ultrasound. Ultrasound is the modality of choice to confirm the diagnosis. The prognosis is favorable, but the evolution can be long. Its management should be structured in a progressive manner, based on therapeutic education and physical measures. These simple measures have the highest level of evidence of effectiveness and should be implemented before proposing, sometimes too early, second-line therapies.

Les talalgies plantaires touchent 4 à 9 % de la population et sont un motif fréquent de consultation en médecine générale et en médecine du sport. L'aponévropathie plantaire en est la cause la plus fréquente. Son diagnostic est essentiellement clinique, éventuellement complété en première intention par le couple radiographie/échographie. Cette dernière est l'examen de choix permettant de confirmer le diagnostic. De pronostic favorable, sa durée d'évolution peut être longue. Sa prise en charge doit être structurée de façon progressive en s'appuyant sur l'éducation thérapeutique et des mesures physiques. Ces mesures simples montrent le niveau de preuve d'efficacité le plus élevé et doivent impérativement être mises en place avant de proposer, parfois trop précocement, des thérapeutiques de seconde intention.

Complex regional pain syndrome of the residual limb in a transtibial lower-limb amputee: diagnosis and treatment.

We present the unusual case of complex regional pain syndrome (CRPS) of the residual limb in a 54-year-old woman with transtibial lower-limb amputation. Intractable pain developed 14 months after amputation, followed by successful rehabilitation. Anamnesis and clinical findings included sensory symptoms, vasomotor symptoms and signs, and oedema. The Budapest criteria for a diagnosis of CRPS were met. After infusions of bisphosphonates during a 5-week inpatient interdisciplinary rehabilitation programme, the pain decreased. Clinicians should suspect CRPS in case of chronic or recurrent residual limb pain. The Budapest criteria seem applicable even if interpretation of symptoms and findings can be complicated in vascular polymorbid lower-limb amputation. Bisphosphonates, proposed as first-line pharmacological treatment, can be useful.

Development and validation of a short version of the French Hand Function Sort questionnaire in vocational rehabilitation.

BACKGROUND: The Hand Function Sort (HFS) is a pictorial self-administered questionnaire with 62 items. It is a valid and reliable scale focused on the physical function of the upper limbs. It is used to predict the return to work. OBJECTIVES: We aimed to develop and validate a short version of the French version of the HFS (HFS-F) to simplify its use in clinical practice. METHODS: We included patients with upper-limb chronic pain hospitalised for vocational rehabilitation from 2012 to 2019. Vocational rehabilitation aims to improve the autonomy of patients to regain their previous working capacity. The 62 items of the HFS-F were analysed in terms of patient and expert assessments, floor/ceiling effect, item-to-total correlation, principal component analysis, and Rasch analysis. A short HFS-F was developed. Thereafter, we assessed its internal consistency, test-retest reliability, criterion validity with the full-length HFS-F, construct validity with different scales (Disabilities of the Arm, Shoulder, and Hand [DASH]; Brief Pain Inventory [BPI]; Hospital Anxiety and Depression [HAD]), standard error of measurement (SEM), and minimal detectable change (MDC). RESULTS: Six experts were consulted, 34 patients were interviewed, and 629 questionnaires were analysed. Among the items, 25 were selected after the final round with the six experts. The internal consistency and test-retest reliability were excellent (Cronbach α=0.95, intraclass correlation coefficient=0.92, 95% confidence interval [95% CI] 0.87 to 0.95). The correlation coefficient between scores of the short and full-length HFS-F was 0.841 (95% CI: 0.752 to 0.897, P<10-4), and those between the short HFS-F score and the DASH, BPI, HAD-Anxiety, and HAD-Depression scores were -0.816 (95% CI: -0.714 to -0.881, P<10-4), -0.529 (95% CI: -0.338 to -0.674, P<10-4), -0.451 (95% CI: -0.244 to 0.614, P=0.0001), and -0.360 (95% CI: -0.140 to -0.542, P=0.0018), respectively. The SEM and MDC values were estimated at 6/100 and 17/100, respectively. CONCLUSIONS: A short version of the HFS-F was developed and validated. We named this questionnaire the 25 HFS-F.

Impact of early sports specialisation on paediatric ECG.

Athletes of pediatric age are growing in number. They are subject to a number of risks, among them sudden cardiac death (SCD). This study aimed to characterize the pediatric athlete population in Switzerland, to evaluate electrocardiographic findings based on the International Criteria for electrocardiography (ECG) Interpretation in Athletes, and to analyze the association between demographic data, sport type, and ECG changes. Retrospective, observational study of pediatric athletes (less than 18 years old) including medical history, physical examination, and a 12-lead resting ECG. The primary focus was on identification of normal, borderline, and abnormal ECG findings. The secondary observation was the relation between ECG and demographic, anthropometric, sport-related, and clinical data. The 891 athletes (mean 14.8 years, 35% girls) practiced 45 different sports on three different levels, representing all types of static and dynamic composition of the Classification of Sports by Mitchell. There were 75.4% of normal ECG findings, among them most commonly early repolarization, sinus bradycardia, and left ventricular hypertrophy; 4.3% had a borderline finding; 2.1% were abnormal and required further investigations, without SCD-related diagnosis. While the normal ECG findings were related to sex, age, and endurance sports, no such observation was found for borderline or abnormal criteria. Our results in an entirely pediatric population of athletes demonstrate that sex, age, and type of sports correlate with normal ECG findings. Abnormal ECG findings in pediatric athletes are rare. The International Criteria for ECG Interpretation in Athletes are appropriate for this age group.

What Motivates Healthcare Professionals' Referrals to Chaplains, and How to Help Them Formulate Referrals that Accurately Reflect Patients' Spiritual Needs?

As many hospitals lack standardized referral protocols for spiritual care, healthcare professionals' perceptions and preferences play an important role in their decisions to refer patients to chaplains. To better understand what motivates these professionals to refer patients and how they approach spiritual care, this article examines referral requests from twelve healthcare professionals to a chaplain at the Lausanne University Hospital Department of Physical and Rehabilitation Medicine. Comparative discourse analysis highlights that requests are largely driven by difficulties in patient-professional relationships. Yet, further interviews reveal that healthcare professionals construct spiritual care as a way to access patients' sense of identity and explore the meaning they give to their lives and experiences, for the benefit of both patients and professionals. The discussion considers how chaplains could help healthcare colleagues formulate referrals that accurately reflect patients' spiritual needs, thus improving the relevance and quality of spiritual care.

Differential Diagnosis Assessment in Ambulatory Care With an Automated Medical History-Taking Device: Pilot Randomized Controlled Trial.

BACKGROUND: Automated medical history-taking devices (AMHTDs) are emerging tools with the potential to increase the quality of medical consultations by providing physicians with an exhaustive, high-quality, standardized anamnesis and differential diagnosis. OBJECTIVE: This study aimed to assess the effectiveness of an AMHTD to obtain an accurate differential diagnosis in an outpatient service. METHODS: We conducted a pilot randomized controlled trial involving 59 patients presenting to an emergency outpatient unit and suffering from various conditions affecting the limbs, the back, and the chest wall. Resident physicians were randomized into 2 groups, one assisted by the AMHTD and one without access to the device. For each patient, physicians were asked to establish an exhaustive differential diagnosis based on the anamnesis and clinical examination. In the intervention group, residents read the AMHTD report before performing the anamnesis. In both the groups, a senior physician had to establish a differential diagnosis, considered as the gold standard, independent of the resident's opinion and AMHTD report. RESULTS: A total of 29 patients were included in the intervention group and 30 in the control group. Differential diagnosis accuracy was higher in the intervention group (mean 75%, SD 26%) than in the control group (mean 59%, SD 31%; P=.01). Subgroup analysis showed a between-group difference of 3% (83% [17/21]-80% [14/17]) for low complexity cases (1-2 differential diagnoses possible) in favor of the AMHTD (P=.76), 31% (87% [13/15]-56% [18/33]) for intermediate complexity (3 differential diagnoses; P=.02), and 24% (63% [34/54]-39% [14/35]) for high complexity (4-5 differential diagnoses; P=.08). Physicians in the intervention group (mean 4.3, SD 2) had more years of clinical practice compared with the control group (mean 5.5, SD 2; P=.03). Differential diagnosis accuracy was negatively correlated to case complexity (r=0.41; P=.001) and the residents' years of practice (r=0.04; P=.72). The AMHTD was able to determine 73% (SD 30%) of correct differential diagnoses. Patient satisfaction was good (4.3/5), and 26 of 29 patients (90%) considered that they were able to accurately describe their symptomatology. In 8 of 29 cases (28%), residents considered that the AMHTD helped to establish the differential diagnosis. CONCLUSIONS: The AMHTD allowed physicians to make more accurate differential diagnoses, particularly in complex cases. This could be explained not only by the ability of the AMHTD to make the right diagnoses, but also by the exhaustive anamnesis provided.

Differences in the miRNA signatures of chronic musculoskeletal pain patients from neuropathic or nociceptive origins.

BACKGROUND: The quality of life for millions of people worldwide is affected by chronic pain. In addition to the effect of chronic pain on well-being, chronic pain has also been associated with poor health conditions and increased mortality. Due to its multifactorial origin, the classification of pain types remains challenging. MicroRNAs (miRNA) are small molecules that regulate gene expression. They are released into the bloodstream in a stable manner under normal and pathological conditions and have been described as potential biomarkers. In the present study, we aimed to investigate whether pain may induce an aberrant, specific dysregulation of miRNA expression, depending on the origin of the pain. METHODS AND FINDINGS: To do so, we measured the expression changes of 184 circulating miRNAs (c-miRNAs) in the plasma samples of patients with different origins of chronic musculoskeletal pain. After statistical analyses, we identified seven c-miRNA candidates that were differentially expressed depending on the nociceptive or neuropathic origin of the pain. We then developed a two c-miRNA signature (hsa-miR-320a and hsa-miR-98-5p) that was able to correctly classify the pain type of 70% of the patients from the validation set. CONCLUSIONS: In conclusion, circulating miRNAs are promising biomarkers to identify and characterize the chronic pain type and to further improve its clinical management.