Pain exacerbation following physical activity in adults with diabetic neuropathy: Ecological momentary assessment of foot symptoms.

BACKGROUND AND OBJECTIVES: People with diabetic peripheral neuropathy (DPN) report fluctuating foot symptoms. This study used ecological momentary assessment to: (1) compare foot symptoms between days, time points and periods with/without preceding physical activity or pain medication; and (2) determine relationships between symptoms and endogenous pain modulation. METHOD: Ten low-active Australian adults with probable DPN underwent temporal summation of pain (TSP) and conditioned pain modulation (CPM) then completed mobile phone surveys five times daily for seven days, where they recorded the intensity of six foot symptoms and whether they performed physical activity or consumed pain medication in the preceding three hours.  RESULTS: All foot symptoms except numbness were greater in periods following physical activity, whereas periods following pain medication showed greater shooting pain. TSP showed very large correlations with sensitivity to touch, burning pain, shooting pain and prickling/tingling.  DISCUSSION: General practitioners should be aware that physical activity might exacerbate symptoms of DPN when encouraging their patients to be active.

Examining the role of mood in pain-limited treadmill walking duration in young healthy individuals.

PURPOSE: The purpose of the study was to examine the effects of acute mood modulation on treadmill walking duration during experimental pain application. METHODS: This was a repeated measure, within-subject study design. 30 healthy individuals (Males: Females 16:14; age 22.9 ± 2.5 years; height 170.9 ± 9.5 cm; body mass 68.4 ± 14.6 kg) attended a familiarization session and three experimental sessions, whereby they simultaneously viewed emotionally evoking stimulus from the International Affective Picture System (IAPS) and performed two treadmill walking tests (maximum 10 min duration) with a fixed nociceptive input applied to the thigh (pressure cuff). The primary outcome was treadmill walking duration during pain application to achieve a fixed pain score. During walking, mood (Self-Assessment Manikin: SAM 0-9) and pain (numerical rating scale: NRS 0-10) were measured. RESULTS: Mood valence scores were significantly different in all conditions (p < 0.001), negative (2.4 ± 0.3), neutral (4.9 ± 0.6) and positive (6.6 ± 0.3). There was a significant difference (p = 0.04) in the treadmill walking duration for different mood states. For the primary outcome, post hoc analysis found differences between the negative and positive mood conditions for the treadmill walking durations to reach pain scores of 3 (negative: 224 ± 49 s; positive: 259 ± 60s, effect size [ES]: 0.80), 4 (negative: 262 ± 59 s; positive: 326 ± 90s, ES: 0.92), 5 (negative: 313 ± 86 s; positive: 385 ± 113 s, ES: 0.90), 6 (negative: 367 ± 106 s; positive: 447 ± 113 s, ES: 1.04) and 7 (negative: 423 ± 114 s; positive: 521 ± 110 s, ES: 1.02). There was no significant difference in the treadmill walking duration between the neutral vs negative mood and neutral vs positive mood conditions. CONCLUSION: These results highlight the potential psychophysiological impacts on the pain experience in healthy individuals and encourages pursuit in strategies to minimize pain-limited exercise, a highly prevalent issue in the chronic pain population. SIGNIFICANCE: Walking-based rehabilitation, designed to improve physical activity, has been shown to improve pain and disability. However active participation and adherence in walking-based rehabilitation has shown to be jeopardized by pain and pain-related cognitive and behavioural adaptations. This study examined the effect of a shift in mood on pain perception and treadmill walking tolerance. We found that with a worse mood, individuals were less tolerant of pain and walked on the treadmill for a shorter duration. These results suggest that factors which improve mood should be combined with walking-based training to improve tolerance.

Personal Activity Intelligence eHealth intervention in people with diabetic peripheral neuropathy: A feasibility study.

BACKGROUND AND OBJECTIVES: People with diabetic peripheral neuropathy (DPN) report difficulty exercising. This study tested an innovative intervention to promote physical activity self-management and its impact on foot symptoms. METHOD: Ten adults with DPN not meeting exercise guidelines consented to four weekly sessions involving exercise tasters, behaviour change counselling and Physical Activity Intelligence (PAI) self-monitoring, with a goal to maintain daily PAI scores ≥100. Foot symptoms were assessed using repeated mobile phone surveys at 0 and 12 weeks. RESULTS: Participants attended a mean 3.5 sessions and achieved 100 PAI on 53% and 15% of days during Weeks 2-4 and 5-12, respectively. No major adverse events and large reductions in aching (P=0.02) and burning pain (P=0.03) in the feet were recorded. DISCUSSION: The PAI eHealth intervention was feasible and safe and might reduce foot symptoms. More work is needed to support self-directed exercise maintenance.

Current rehabilitation recommendations following primary triangular fibrocartilage complex foveal repair surgery: A survey of Australian hand therapists.

BACKGROUND: Following injury to the Triangular Fibrocartilage Complex (TFCC), foveal repair surgery may be indicated to restore joint stability and function. Protection of the repaired ligament is a clinical consideration during post-surgical rehabilitation, although no "gold standard" rehabilitation protocol currently exists. PURPOSE: To describe the professional opinions of Accredited Hand Therapists (AHT) regarding post-operative rehabilitation recommendations following TFCC foveal repair surgery. STUDY DESIGN: Cross-sectional descriptive study. METHODS: All Australian AHTs were invited to complete a quantitative, online, 10-item survey between December 2019 and March 2020. The survey included questions regarding clinical recommendations for wrist and forearm immobilization, range of motion and exercise methods, and timeframes. AHT characteristics and experience of patients sustaining a TFCC re-rupture were also collected. Categorical and nominal survey responses were reported descriptively and effects of AHT characteristics on survey responses were assessed using Pearson Chi2, with significance set to <0.05. RESULTS: Survey responses were received from 135 AHTs or approximately 37% of the available population at the time of completion (March 2020). Recommendations for post-surgery immobilization ranged from "not required" to 8 weeks, 6 weeks representing the most common answer. Wrist and forearm range of motion commencement time ranged from "immediately" to "later than 8 weeks," with 6 weeks also the most common answer. When asked whether post-surgery rupture had been experienced in their respective patient groups, 15 therapists (11%) indicated "Yes." The most recommended thermoplastic orthosis was a Sugartong orthosis (41%) followed by a Muenster orthosis (30%), both of which immobilizes the wrist and forearm. CONCLUSIONS: Rehabilitation varied widely between AHTs. Further prospective research is recommended to explore whether patient-related or rehabilitation factors influence outcomes following TFCC repair.

Are clinical outcomes associated with baseline sensory profiles in people with musculoskeletal shoulder pain? Protocol for a prospective longitudinal observational study.

BACKGROUND: Musculoskeletal shoulder pain is a common problem and its symptoms often become persistent. The experience of pain is multidimensional, and therefore, a range of patient characteristics may influence treatment response. An altered sensory processing has been associated with persistent musculoskeletal pain states and may contribute to outcomes in patients with musculoskeletal shoulder pain. The presence and potential impact of altered sensory processing in this patient cohort is not currently known. The aim of this prospective longitudinal cohort study is to investigate if baseline sensory characteristics are associated with clinical outcomes in patients presenting to a tertiary hospital with persistent musculoskeletal shoulder pain. If found, a relationship between sensory characteristics and outcome may lead to the creation of more effective treatment strategies and improvements in risk adjustment and prognosis. METHODS: This is a single-centre prospective cohort study with 6-, 12- and 24-month follow-up. A total of 120 participants aged ≥18 years with persistent musculoskeletal shoulder pain (≥3 months) will be recruited from an Australian public tertiary hospital orthopaedic department. Baseline assessments, including quantitative sensory tests and a standardised physical examination, will be performed. In addition, information will be obtained from patient interviews, self-report questionnaires and medical records. Follow-up outcome measures will comprise information from the Shoulder Pain and Disability Index and a six-point Global Rating of Change scale. ANALYSIS: Descriptive statistics will be used to report baseline characteristics and outcome measures over time. Change in outcome measures at the primary endpoint of six months from baseline will be calculated using paired t-tests. Associations between baseline characteristics and outcomes at a 6-month follow-up will be reported using multivariable linear and logistic regression models. DISCUSSION: Understanding the relationship between sensory profile and the variable response to treatment in people with persistent musculoskeletal shoulder pain may enhance our understanding of the mechanisms contributing to the presentation. In addition, through better understanding of the contributing factors, the results of this study may contribute to the development of an individualised, patient-centred approach to treatment for people with this highly prevalent and debilitating condition.

Immediate response to injection is associated with conservative care outcomes at 12 weeks in subacromial shoulder pain.

BACKGROUND: Subacromial injection is known to influence pain of subacromial origin, yet its association with conservative care outcomes is unknown. This study investigated whether immediate response to subacromial injection of corticosteroid and local anaesthetic is associated with conservative care outcomes at 12 weeks post injection and/or progression to surgery. DESIGN: prospective prognostic cohort study. METHODS: Sixty-four participants with subacromial related shoulder pain attending initial orthopaedic outpatient appointment at an Australian public hospital, received subacromial injection of corticosteroid and local anaesthetic followed by up to 12 weeks of physiotherapy. Immediate response to injection was measured by change in shoulder range of motion (ROM) and pain immediately (within 20 min) before and after injection. The Shoulder Pain and Disability Index (SPADI) was measured at baseline, 6 and 12-weeks. RESULTS: Backward stepwise linear regression revealed immediate post-injection improvement in pain-free ROM (p = 0.001) and higher baseline symptoms (p = 0.016) were significantly associated with better 12-week SPADI outcomes. Longer symptom duration (p = 0.029) and higher age (p = 0.013) were significantly associated with poorer outcomes. Only 11 individuals progressed to surgery. The resultant model could explain 35% of the variation in change in SPADI at 12 weeks. CONCLUSION: Improvement in pain-free shoulder ROM immediately post injection is significantly associated with better 12-week conservative care outcomes. This information, derived from within consultation injection responses, could help inform decisions about potential treatment options. Further research with higher numbers and longer-term patient-reported outcomes could further clarify these findings. REGISTRATION: Australia and New Zealand Clinical Trials Registry 21 May 2012: 12612000532808.

Wrist and forearm range of motion commencement time following primary triangular fibrocartilage complex foveal repair surgery: A scoping review.

STUDY DESIGN: Scoping review. BACKGROUND: Rehabilitation guidelines following triangular fibrocartilage complex (TFCC) foveal repair surgery have been inconsistently reported in the published literature, with no consensus regarding wrist or forearm range of motion (ROM) commencement time. PURPOSE OF THE STUDY: To scope the available literature to identify the extent and strength of the evidence supporting the clinical guidelines for wrist and forearm ROM commencement time following primary TFCC foveal repair surgery. METHODS: A systematic search produced 26 studies (3 retrospective cohort studies, 1 prospective cohort study, 1 retrospective comparative study, and 21 retrospective case series) that described specific rehabilitation protocols following TFCC foveal repair surgery. RESULTS: No supporting evidence was identified regarding rehabilitation protocol recommendations across all the included studies. Postsurgery wrist ROM commencement ranged from 2 to 8 weeks; forearm ROM commencement ranged from 2 to 12 weeks. ROM commencement times did not appear to systematically influence the rate of adverse events, although adverse events were poorly reported. CONCLUSIONS: TFCC rehabilitation protocols were poorly reported and varied widely between the included studies. Additional research is recommended to comprehensively evaluate the association between wrist and/or forearm ROM and the rate of adverse events for this complex and multifaceted condition.

ICON 2020-International Scientific Tendinopathy Symposium Consensus: A Scoping Review of Psychological and Psychosocial Constructs and Outcome Measures Reported in Tendinopathy Clinical Trials.

OBJECTIVE: To identify and describe the psychological and psychosocial constructs and outcome measures used in tendinopathy research. DESIGN: Scoping review. LITERATURE SEARCH: We searched the PubMed, EMBASE, Scopus, Web of Science, PEDro, CINAHL, and APA PsychNet databases on July 10, 2021, for all published studies of tendinopathy populations measuring psychological and psychosocial factors. STUDY SELECTION: Studies using a clinical diagnosis of tendinopathy or synonyms (eg, jumper's knee or subacromial impingement) with or without imaging confirmation. DATA SYNTHESIS: We described the volume, nature, distribution, and characteristics of psychological and psychosocial outcomes reported in the tendinopathy field. RESULTS: Twenty-nine constructs were identified, including 16 psychological and 13 psychosocial constructs. The most frequently-reported constructs were work-related outcomes (32%), quality of life (31%), depression (30%), anxiety (18%), and fear (14%). Outcome measures consisted of validated and nonvalidated questionnaires and 1-item custom questions (including demographics). The number of different outcome measures used to assess an individual construct ranged between 1 (emotional distress) and 11 (quality of life) per construct. CONCLUSION: There was a large variability in constructs and outcome measures reported in tendinopathy research, which limits conclusions about the relationship between psychological and psychosocial constructs, outcome measures, and tendinopathies. Given the wide range of psychological and psychosocial constructs reported, there is an urgent need to develop a core outcome set in tendinopathy. J Orthop Sports Phys Ther 2022;52(6):375-388. doi:10.2519/jospt.2022.11005.

Diabetic Neuropathy in Hands: An Endemic Complication Waiting to Unfold?

In this cross-sectional study we aimed to quantify the somatosensory dysfunction in the hand in people with diabetes with distal symmetrical polyneuropathy (DSPN) in hands and explore early signs of nerve dysfunction in people with diabetes without DSPN in hands. The clinical diagnosis of DSPN was confirmed with electrodiagnosis and corneal confocal microscopy. Thermal and mechanical nerve function in the hand was assessed with quantitative sensory tests. Measurements were compared between healthy participants (n = 31), individuals with diabetes without DSPN (n = 35), individuals with DSPN in feet but not hands (DSPNFEET ONLY) (n = 31), and individuals with DSPN in hands and feet (DSPNHANDS & FEET) (n = 28) with one-way between-group ANOVA. The somatosensory profile of the hand in people with DSPNHANDS & FEET showed widespread loss of thermal and mechanical detection. This profile in hands is comparable with the profile in the feet of people with DSPN in feet. Remarkably, individuals with DSPNFEET ONLY already showed a similar profile of widespread loss of nerve function in their hands. People with diabetes without DSPN in feet already had some nerve dysfunction in their hands. These findings suggest that nerve function assessment in hands should become more routine in people with diabetes.

International physical therapists consensus on clinical descriptors for diagnosing rotator cuff related shoulder pain: A Delphi study.

BACKGROUND: There is a lack of standardized criteria for diagnosing rotator cuff related shoulder pain (RCRSP). OBJECTIVE: To identify the most relevant clinical descriptors for diagnosing RCRSP. METHODS: A Delphi study was conducted through use of an international physical therapists expert panel. A 3-round Delphi survey involving an international panel of physical therapists experts with extensive clinical, teaching, and research experience was conducted. A search query was performed in Web of Science, along with a manual search, to find the experts. The first round was composed of items obtained from a previous pilot Delphi study along with new items proposed by the experts. Participants were asked to rate items across six clinical domains using a five-point Likert scale. An Aiken's Validity Index ≥ 0.7 was considered indicative of group consensus. RESULTS: Fifteen experts participated in the Delphi survey. After the three rounds, consensus was reached on 18 clinical descriptors: 10 items were included in the "subjective examination" domain, 1 item was included in the "patient-reported outcome measures" domain, 3 items in the "diagnostic examination" domain, 2 items in the "physical examination" domain", and 2 items in the "functional tests" domain. No items reached consensus within the "special tests" domain. The reproduction of symptoms in relation to the application of load, the performance of overhead activities, and the need of active and resisted movement assessment were some of the results with greatest consensus. CONCLUSION: In this Delphi study, a total of 18 clinical descriptors across six clinical domains were agreed upon for diagnosing RCRSP.

Investigating the effects of mobilization with movement and exercise on pain modulation processes in shoulder pain - a single cohort pilot study with short-term follow up.

OBJECTIVE: To explore the association between manual therapy and exercise and pain modulation and clinical characteristics in people with musculoskeletal shoulder pain. METHODS: This is a prospective, longitudinal, single cohort pilot study. People with shoulder pain for longer than 6 weeks underwent 4 weeks of glenohumeral mobilization with movement and shoulder exercises. Measures of pain modulation, shoulder pain, disability, range of motion and psychosocial factors were assessed at baseline and immediately after the 4-week period of treatment. Treatment effectiveness was assessed through parametric, non-parametric and multilevel modeling statistics. RESULTS: Twenty-three individuals participatedwith no loss to follow-up. Significant and meaningful improvements in shoulder pain (NRS mean change 1.6/10, 95% CI 0.4 to 2.7), disability (SPADI mean change 20.5/100, 95% CI 13.1 to 27.9) and range of motion (mean change 33°, 95% CI 23 to 43°) were observed following treatment. Statistical but non-clinically meaningful changes were observed in temporal summation of pain (mean change 0.3/10, 95% CI 0.1 to 0.4) and anxiety (mean change 0.86/21, 95% CI 0.18 to 1.55). Significant reductions were observed in temporal summation of pain (mean change 0.3/10, 95% CI 0.1 to 0.4) and anxiety (mean change 0.86/21, 95% CI 0.18 to 1.55), however these were not considered clinically important. No association was found between clinical characteristics and sensory measures. No association was found between clinical characteristics and sensory measures. CONCLUSION: Glenohumeral mobilization with movement and exercise did not improve pain modulation, despite improvements in pain, function and range of motion, in people with shoulder pain.

Development of a core outcome set for lateral elbow tendinopathy (COS-LET) using best available evidence and an international consensus process.

OBJECTIVES: To develop a core outcome set for lateral elbow tendinopathy (COS-LET) and to provide guidance for outcome evaluation in future studies. METHODS: We implemented a multi-stage mixed-methods design combining two systematic reviews, domain mapping of outcome measurement instruments to the core domains of tendinopathy, psychometric analysis of instruments, two patient focus groups and a Delphi study incorporating two surveys and an international consensus meeting. Following the OMERACT guidelines, we used a 70% threshold for consensus. RESULTS: 38 clinicians/researchers and 9 patients participated. 60 instruments were assessed for inclusion. The only instrument that was recommended for the COS-LET was Patient Rated Tennis Elbow Evaluation (PRTEE) for the disability domain. Interim recommendations were made to use: the PRTEE function subscale for the function domain; PRTEE pain subscale items 1, 4 and 5 for the pain over a specified time domain; pain-free grip strength for the physical function capacity domain; a Numerical Rating Scale measuring pain on gripping for the pain on activity/loading domain; and time off work for the participation in life activities domain. No recommendations could be made for the quality-of-life, patient rating of condition and psychological factors domains. CONCLUSIONS: The COS-LET comprises the PRTEE for the disability domain. Interim-use recommendations included PRTEE subscales, time off work, pain-free grip strength and a Numerical Rating Scale measuring pain on gripping. Further work is required to validate these interim measures and develop suitable measures to capture the other domains.

The prevalence and burden of recurrent headache in Australian adolescents: findings from the longitudinal study of Australian children.

BACKGROUND: Headache disorders are highly prevalent worldwide, but not well investigated in adolescents. Few studies have included representative nationwide samples. This study aimed to present the prevalence and burden of recurrent headache in Australian adolescents. METHODS: The prevalence of recurrent headache, headache characteristics (severity and frequency) and burden on health-related quality of life in Australian children aged 10-17 years were presented, using nationally representative data from the Longitudinal Study of Australian children (LSAC). The LSAC, commencing in 2004, collects data every 2 years from a sample of Australian children of two different age cohorts: B 'baby' cohort, aged 0-1 years and K 'kindergarten' cohort, aged 4-5 years at the commencement of the study. Face-to-face interviews and self-complete questionnaires have been conducted with the study child and parents of the study child (carer-reported data) at each data collection wave, with seven waves of data available at the time of the current study. Wave 7 of the LSAC was conducted in 2016, with B cohort children aged 12-13 years and K cohort children aged 16-17 years. For the current study, data were accessed for four out of seven waves of available data (Wave 4-7) and presented cross-sectionally for the two cohorts of Australian children, for the included age groups (10-11 years, 12-13 years, 14-15 years and 16-17 years). All available carer-reported questionnaire data pertaining to headache prevalence, severity and frequency, general health and health-related quality of life, for the two cohorts, were included in the study, and presented for male and female adolescents. Carer-reported general health status of the study child and health-related quality of life scores, using the parent proxy-report of the Paediatric Quality of Life Inventory™ 4.0, were compared for male and female adolescents with recurrent headache and compared with a healthy group. Finally, health-related quality of life scores were compared based on headache frequency and severity. RESULTS: The LSAC study initially recruited 10,090 Australian children (B cohort n = 5107, K cohort n = 4983), and 64.1% of the initial sample responded at wave 7. Attrition rates across the included waves ranged from 26.3% to 33.8% (wave 6 and 7) for the B cohort, and 16.3% to 38.0% (wave 4-7) for the K cohort. Recurrent headache was more common in females, increasing from 6.6% in 10-11 years old females to 13.2% in 16-17 years old females. The prevalence of headache in males ranged from 4.3% to 6.4% across the age groups. Health-related quality of life scores were lower for all functional domains in adolescents with recurrent headache, for both sexes. Headache frequency, but not severity, was significantly associated with lower health-related quality of life scores, in both males and females. CONCLUSIONS: Recurrent headache was common among Australian adolescents and increased in prevalence for females, across the age groups. Frequent recurrent headache is burdensome for both male and female adolescents. This study provides information regarding the prevalence and burden of recurrent headache in the adolescent population based on findings from the Longitudinal Study of Australian Children.

Protocol for the development of a core outcome set for lateral elbow tendinopathy (COS-LET).

BACKGROUND: Lateral elbow tendinopathy (LET) is a common condition that can cause significant disability and associated socioeconomic cost. Although it has been widely researched, outcome measures are highly variable which restricts evidence synthesis across studies. In 2019, a working group of international experts, health care professionals and patients, in the field of tendinopathy (International Scientific Tendinopathy Symposium Consensus (ICON) Group), published the results of a consensus exercise defining the nine core domains that should be measured in tendinopathy research. The aim of this study is to develop a core outcome set (COS) for LET mapping to these core domains. The primary output will provide a template for future outcome evaluation of LET. In this protocol, we detail the methodological approach to the COS-LET development. METHODS: This study will employ a three-phase approach. (1) A systematic review of studies investigating LET will produce a comprehensive list of all instruments currently employed to quantify the treatment effect or outcome. (2) Instruments will be matched to the list of nine core tendinopathy outcome domains by a Steering Committee of clinicians and researchers with a specialist interest in LET resulting in a set of candidate instruments. (3) An international three-stage Delphi study will be conducted involving experienced clinicians, researchers and patients. Within this Delphi study, candidate instruments will be selected based upon screening using the Outcome Measures in Rheumatology (OMERACT) truth, feasibility and discrimination filters with a threshold of 70% agreement set for consensus. CONCLUSIONS: There is currently no COS for the measurement or monitoring of LET in trials or clinical practice. The output from this project will be a minimum COS recommended for use in all future English language studies related to LET. The findings will be published in a high-quality journal and disseminated widely using professional networks, social media and via presentation at international conferences. TRIAL REGISTRATION: Registered with the Core Outcome Measures in Effectiveness Trials (COMET) database, November 2019. https://www.comet-initiative.org/Studies/Details/1497 .

Altered pain processing in patients with type 1 and 2 diabetes: systematic review and meta-analysis of pain detection thresholds and pain modulation mechanisms.

The first signs of diabetic neuropathy typically result from small-diameter nerve fiber dysfunction. This review synthesized the evidence for small-diameter nerve fiber neuropathy measured via quantitative sensory testing (QST) in patients with diabetes with and without painful and non-painful neuropathies. Electronic databases were searched to identify studies in patients with diabetes with at least one QST measure reflecting small-diameter nerve fiber function (thermal or electrical pain detection threshold, contact heat-evoked potentials, temporal summation or conditioned pain modulation). Four groups were compared: patients with diabetes (1) without neuropathy, (2) with non-painful diabetic neuropathy, (3) with painful diabetic neuropathy and (4) healthy individuals. Recommended methods were used for article identification, selection, risk of bias assessment, data extraction and analysis. For the meta-analyses, data were pooled using random-effect models. Twenty-seven studies with 2422 participants met selection criteria; 18 studies were included in the meta-analysis. Patients with diabetes without symptoms of neuropathy already showed loss of nerve function for heat (standardized mean difference (SMD): 0.52, p<0.001), cold (SMD: -0.71, p=0.01) and electrical pain thresholds (SMD: 1.26, p=0.01). Patients with non-painful neuropathy had greater loss of function in heat pain threshold (SMD: 0.75, p=0.01) and electrical stimuli (SMD: 0.55, p=0.03) compared with patients with diabetes without neuropathy. Patients with painful diabetic neuropathy exhibited a greater loss of function in heat pain threshold (SMD: 0.55, p=0.005) compared with patients with non-painful diabetic neuropathy. Small-diameter nerve fiber function deteriorates progressively in patients with diabetes. Because the dysfunction is already present before symptoms occur, early detection is possible, which may assist in prevention and effective management of diabetic neuropathy.

Prolotherapy injections and physiotherapy used singly and in combination for lateral epicondylalgia: a single-blinded randomised clinical trial.

BACKGROUND: Lateral epicondylalgia (tennis elbow) is a common, debilitating and often treatment-resistant condition. Two treatments thought to address the pathology of lateral epicondylalgia are hypertonic glucose plus lignocaine injections (prolotherapy) and a physiotherapist guided manual therapy/exercise program (physiotherapy). This trial aimed to compare the short- and long-term clinical effectiveness, cost effectiveness, and safety of prolotherapy used singly and in combination with physiotherapy. METHODS: Using a single-blinded randomised clinical trial design, 120 participants with lateral epicondylalgia of at least 6 weeks' duration were randomly assigned to prolotherapy (4 sessions, monthly intervals), physiotherapy (weekly for 4 sessions) or combined (prolotherapy+physiotherapy). The Patient-Rated Tennis Elbow Evaluation (PRTEE) and participant global impression of change scores were assessed by blinded evaluators at baseline, 6, 12, 26 and 52 weeks. Success rate was defined as the percentage of participants indicating elbow condition was either 'much improved' or 'completely recovered.' Analysis was by intention-to-treat. RESULTS: Eighty-eight percent completed the 12-month assessment. At 52 weeks, there were substantial, significant improvements compared with baseline status for all outcomes and groups, but no significant differences between groups. The physiotherapy group exhibited greater reductions in PRTEE at 12 weeks than the prolotherapy group (p = 0.014). CONCLUSION: There were no significant differences amongst the Physiotherapy, Prolotherapy and Combined groups in PRTEE and global impression of change measures over the course of the 12-month trial. TRIAL REGISTRATION: ACTRN12612000993897 .

Identifying psychosocial characteristics that predict outcome to the UPLIFT programme for people with persistent back pain: protocol for a prospective cohort study.

INTRODUCTION: Prognostic screening of people with low back pain (LBP) improves utilisation of primary healthcare resources. Whether this also applies to secondary healthcare remains unclear. Therefore, this study aims to develop prognostic models to determine at baseline which patients with persistent LBP are likely to have a good and poor outcome to a 5-week programme of combined education and exercise ('UPLIFT') delivered in a secondary healthcare setting. METHODS AND ANALYSIS: A prospective cohort study of 246 people with persistent LBP will be conducted in a secondary healthcare outpatient setting. Patients will be recruited from a physiotherapy-led neurosurgical screening clinic. Demographic data, medical history and psychosocial characteristics will be recorded at baseline. Fear avoidance beliefs, pain self-efficacy, LBP treatment beliefs, pain catastrophising, perceived injustice, depression, anxiety and stress, disability level, pain intensity and interference, health status and social connectedness will be considered as potential prognostic variables, which will be assessed using self-reported questionnaires. Participants will attend the UPLIFT programme, consisting of weekly 90 min group sessions that combine interactive education sessions and a graded exercise programme. The outcome measure to identify good and poor outcome is the Global Rating of Change scale, assessed at completion of the UPLIFT programme and at 6 months follow-up. Multiple imputation analyses will be performed for missing values. Prognostic models will be developed using multivariable logistic regression analyses, with bootstrapping techniques for internal validation. We will calculate the explained variance of the models and the area under the receiver operating characteristic curve. Furthermore, we will determine whether participation in the UPLIFT programme is associated with changes in psychosocial characteristics. ETHICS AND DISSEMINATION: Gold Coast Health Service Human Research Ethics Committee (HREC/18/QGC/41) and the Griffith University Human Research Ethics Committee (GU Ref No: 2018/408) approved the study. Dissemination of findings will occur via peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12618001525279.

Intracortical motor networks are affected in both the contralateral and ipsilateral hemisphere during single limb cold water immersion.

NEW FINDINGS: What is the central question of this study? How does single limb cold water immersion affect corticomotor function and intracortical circuitry in the motor cortex of each cerebral hemisphere? What is the main finding and its importance? Immersion of a single limb in very cold water caused an increase in corticomotor excitability and intracortical facilitation, and a decrease in intracortical inhibition, in the motor cortex of both hemispheres. These findings provide evidence that intense sensory stimuli induce widespread changes in motor circuitry in the contralateral, as well as the ipsilateral, hemisphere. ABSTRACT: Although responses to noxious stimuli have been extensively studied for the contralateral hemisphere, little is known about how the ipsilateral hemisphere may be affected. Therefore, this study examined how exposing a single limb to noxious cold stimuli affects motor output arising from both the contralateral and ipsilateral hemisphere. A total of 17 healthy adults participated in three experiments. Single- and paired-pulse TMS protocols were used to identify how immersing a single upper limb in cold water (4.0 ± 0.5 °C) affects inhibitory and facilitatory circuits in the primary motor cortex (M1) of the contralateral (experiment 1) and ipsilateral (experiment 2) hemisphere. The third experiment used a reaction time task to assess the functional consequences of acute adaptations in the ipsilateral M1. The target muscle in all experiments was the extensor carpi radialis brevis (ECRB). Immersion of a single limb in cold water increased self-perception of pain and temperature, and increased EMG amplitude of the immersed limb. During immersion, motor evoked potentials and intracortical facilitation increased, whereas short interval intracortical inhibition decreased, for both the ipsilateral M1 and contralateral M1. Activity in the ipsilateral hemisphere to the limb immersed in cold water also slowed reaction time for the non-immersed limb. Our findings suggest that altered motor responses from single limb cold water immersion are not restricted to a single hemisphere. Instead, widespread activation of somatosensory systems influences inhibitory and facilitatory circuits in the primary motor cortex of each hemisphere.

Shoulder pain cost-of-illness in patients referred for public orthopaedic care in Australia.

Objective The aim of this study was to calculate the societal economic burden of shoulder pain in patients on the orthopaedic waiting list at an Australian public hospital and calculate the cost (from the government's perspective) of care delivered by the hospital for those patients. Methods A cost-of-illness analysis was undertaken in a cohort of 277 orthopaedic patients on the Gold Coast in Australia. Outcomes included a health care costs and impacts questionnaire, work absenteeism, presenteeism questionnaires (Work Limitations Questionnaire (WLQ) and Work Productivity and Activity Impairment Questionnaire (WPAI)) and hospital care provision over a 2-year period. Results The mean societal cost of healthcare and domestic support was AU$20.72 per day (AU$7563 annually) per patient on the orthopaedic waiting list. When absenteeism and presenteeism were included, the cost per patient who was employed was AU$38.04 per day (AU$13885 annually) calculated with the WLQ and AU$61.31 per day (AU$22378 annually) calculated with the WPAI. The mean per-patient cost to government of public hospital care was AU$2622 in Year 1 and AU$3835.78 (s.d. 4961.28) over 2 years. The surgical conversion rate was 22%, and 51% of hospital care cost was attributable to outpatient services. Conclusions Public orthopaedic shoulder waiting lists create a large economic burden for society; few referrals require surgery and just over half the hospital care costs are for out-patient services. New models of care that better manage shoulder pain and identify surgical candidates before orthopaedic referral could reduce this burden. What is known about the topic? Little is known about the cost of shoulder pain in Australia, or the cost of patients referred for public orthopaedic care. What does this paper add? This article quantifies the costs of shoulder pain and the value of lost production from shoulder pain. The time spent waiting for public hospital orthopaedic appointments and the costs associated with waiting demonstrate that the time spent on a waiting list is a key driver of the economic burden. What are the implications for practitioners? Greater resourcing to reduce public orthopaedic shoulder waiting lists may be helpful, but system change is also required. Earlier and more accurate identification of surgical cases could reduce inefficient referrals and improve hospital productivity. Collaboration between clinicians and policy makers is needed to design more economically efficient shoulder care.

People with musculoskeletal shoulder pain demonstrate no signs of altered pain processing.

BACKGROUND: Central sensitisation may contribute to persistent musculoskeletal shoulder pain. Few studies have provided a comprehensive sensory and psychosocial evaluation of this population. OBJECTIVE: To comprehensively assess whether sensory function and psychosocial aspects are impaired in people with shoulder pain and whether age, gender and clinical outcomes are related to impaired sensory function. STUDY DESIGN: Observational case-control study. METHODS: Twenty-three participants with musculoskeletal shoulder pain and 23 age- and gender-matched healthy participants were included. Static (pressure and thermal pain thresholds) and dynamic (temporal summation) quantitative sensory testing was performed bilaterally at the shoulder and remote tibialis anterior muscle. Conditioned pain modulation was measured at the affected/matched shoulder. Shoulder function (SPADI), depression, anxiety and stress (DASS-21) and health-related quality of life (EQ-5D-5L) were also measured. Comparisons were performed between body regions and groups. Age and gender were included as factors in analyses. Clinical outcomes were tested for correlation with sensory measures. RESULTS: Shoulder pain group had higher local pressure pain threshold (i.e., hypoalgesia; p = 0.03; Z = 0-5.04), higher SPADI score (p < 0.01; Z = -5.76) and higher EQ-5D-5L (p < 0.01; Z = 5.23) compared to the control group. There was no difference between groups for thermal pain sensitivity, dynamic sensory testing or psychological measures. CONCLUSION: People with shoulder pain demonstrated mechanical hypoalgesia, increased upper limb disability and poorer quality of life compared with healthy controls. Central sensitisation seems not be a characteristic of musculoskeletal shoulder pain although it could be present in a subgroup of patients.