Exercise-induced changes in central sensitization outcomes in individuals with chronic musculoskeletal pain: A systematic review with meta-analysis.

BACKGROUND AND OBJECTIVE: Temporal summation of pain (TSP) and conditioned pain modulation (CPM) are the two most commonly used clinical measures of central sensitization (CS). However, the effectiveness of exercise on TSP and CPM has yet to be evaluated. This review aims to investigate the effect of exercise alone on CS outcomes in individuals with chronic musculoskeletal pain. DATABASES AND DATA TREATMENT: This is a systematic review and meta-analysis. MEDLINE, EMBASE, CINAHL, PEDro and Cochrane databases were searched. Data were extracted based on the exercise modality and grouped into aerobic, resistance, isometric, or motor control modalities. Risk of bias was assessed using RoB2, RoB2 for crossover trials and ROBINS-I tools. Quality of evidence was assessed using GRADE. Random-effects meta-analyses were conducted, with subgroup analysis conducted for each exercise modality. RESULTS: The meta-analyses included thirteen studies, consisting of eight non-randomized studies, three randomized controlled trials and three randomized crossover trials. Data were categorized into four subgroups for analyses based on exercise modality. No statistically significant effect existed for both TSP and conditioned pain modulation. However, motor control exercise was found to have a significant enhancing effect on conditioned pain modulation. No significant differences were found between the exercise subgroup for both TSP and conditioned pain modulation. CONCLUSIONS: We did not find an overall effect of physical exercise on TSP and CPM. However, subgroup analysis shows favourable effects of motor control exercise in individuals with chronic neck pain. Future research should focus on exercise modality and dosage and their role in the mechanism involved in TSP and CPM in predefined populations. SIGNIFICANCE STATEMENT: Results from this study found that motor control exercise has a significant enhancing effect on conditioned pain modulation, with subgroup analysis showing favourable effects of motor control exercise in individuals with chronic neck pain. This indicates that physical exercise may have a positive effect on central sensitisation in individual with chronic neck pain. However, differential effects may exist between different types of exercise. These findings will inform understanding of neurobiological effects underlying chronic neck pain and may guide the development of more effective, personalised treatments.

Patient-related barriers and enablers to the implementation of high-value physiotherapy for chronic pain: a systematic review.

OBJECTIVE: To identify and synthesize patient-related barriers to and enablers of the implementation of high-value physiotherapy (HVP) for chronic pain. Furthermore, to review what patient-related interventions have been used to facilitate the implementation of HVP for chronic pain, as well as their efficacy. METHODS: We systematically searched the APA PsycInfo, Embase, CINAHL, Medline, Scopus, and PEDro databases for peer-reviewed studies (published in English) of adults with chronic pain. We used the Theoretical Domains Framework of behavior change to synthesize identified themes relating to barriers and enablers. Outcomes from studies reporting on interventions were also qualitatively synthesized. RESULTS: Fourteen studies reported on barriers and enablers, 8 of which related to exercise adherence. Themes common to barriers and enablers included perceived efficacy of treatment, interrelationship with the physiotherapist, exercise burden, and the patient's understanding of exercise benefits. Other barriers included fear of movement, fragmented care, and cost. Ten studies explored interventions, 9 of which aimed to improve exercise adherence. Of these, evidence from 4 randomized controlled trials of technology-based interventions demonstrated improved exercise adherence among intervention groups compared with controls. CONCLUSION: Patients with chronic pain experience barriers to HVP, including their beliefs, the nature of their interaction with their physiotherapist, perceived treatment efficacy, and cost. Enablers include rapport with their physiotherapist, achievable exercises, and seamless cost-effective care. Technology-based interventions have demonstrated effectiveness at increasing exercise adherence. Our findings suggest that interventions seeking to enhance implementation of HVP need to consider the multifactorial barriers experienced by patients with chronic pain. STUDY REGISTRATION: Open Science Framework (https://doi.org/10.17605/OSF.IO/AYGZV).

Effectiveness of combined surgical and exercise-based interventions following primary traumatic anterior shoulder dislocation: a systematic review and meta-analysis.

OBJECTIVE: To investigate the effectiveness, risk of recurrence and return to activity (RTA) of surgery combined with exercise-based interventions (EBI) versus EBI alone after traumatic anterior shoulder dislocation (ASD). DESIGN: Systematic review and meta-analysis. DATA SOURCES: Systematic literature search (MEDLINE, Web of Science, Scopus, Google Scholar). ELIGIBILITY: Studies focused on EBI or EBI as a part of postoperative care for adults with an ASD, written in English, and published after 1990. We excluded diagnostic, assessment-based studies on individuals experiencing recurrent shoulder dislocations, concomitant shoulder injury, animal or cadaveric studies. Primary outcomes were dislocation RTA. Secondary outcomes were self-reported outcome measures, strength and range of motion. Random-effects meta-analysis was used to estimate the effect of EBI (SMD; Hedges' g, RR). The Grading of Recommendations Assessment, Development and Evaluation approach was used to assess the certainty of evidence. RESULTS: Sixty studies were included (n=3598); seven were meta-analysed (n=345). The mean age of participants in the included studies was 26.71±9.19 and 56% of those included were male. Of the 60 studies included in the systematic review, 29 were fair quality (48.3%), 15 studies were good quality (25%) and 16 studies were poor quality (26.7%), (k=0.66). Individuals who underwent EBI alone were 2.03 times more likely to experience recurrent instability than individuals who underwent EBI in conjunction with surgery (RR 2.03, 95% CI 1.03 to 3.97). Individuals who underwent EBI with surgery appeared 1.81 times more likely to RTA than those who underwent EBI alone, although results were not statistically significant (RR 1.81, 95% CI 0.96 to 3.43). CONCLUSIONS: Surgery combined with EBI is more effective in reducing the risk of recurrence and possibly increasing RTA than EBI alone after traumatic ASD.

Manual handling amongst physiotherapists: Analysis of intra-shift variations in pain, fatigue and movement.

BACKGROUND: Manual handling injuries amongst physiotherapists are common and the need to improve our understanding of causal influences is imperative. OBJECTIVE: The objective was to determine whether intra-shift variations in manual handling task performance occurred in our cohort, which may inform mechanisms underpinning related injuries. METHODS: We used motion capture, force plate dynamics and electromyography to identify variations in task performance, loading forces and muscle activity, during the performance of one static and one dynamic standardized manual handling task, pre- and post-shift, by 40 physiotherapists. Participants also rated their pain and fatigue on a visual analogue scale (VAS). Statistical analysis utilised paired samples Student's t tests. RESULTS: Significant differences were seen in the EMG activity in the quadriceps during the static task only. No significant differences were seen for any of the kinematic variables. Significant differences in fatigue (p < 0.005) were seen between the pre- and post-shift sessions. Notably, there were significant differences in pain between the pre- and post-shift sessions in the static (p < 0.01) and dynamic tasks (p < 0.05). This increase in pain was at a level which impacted on function. CONCLUSION: Whilst significant variations in task performance were not observed, our findings indicate that physiotherapists frequently experience task-related pain towards the end of their shift. Contemporary research indicates that frequent transient low back pain may transition to a chronic disabling condition, as such we posit that the effects of intra-shift pain, and its causative factors, should be more widely considered in a 'whole-of-job' approach to mitigating risk in this demographic.

Do Chronic Low Back Pain and Chronic Widespread Pain differ in their association with Depression Symptoms in the 1958 British Cohort?

OBJECTIVE: Depression frequently coexists with chronic pain. Contemporary models suggest that these conditions share pathobiological mechanisms, prompting a need to investigate their temporal association. This investigation aimed to explore two distinctly different chronic pain conditions, and their cross-sectional and prospective associations with depression. METHODS: Self-reported information was available on chronic widespread pain (CWP), chronic low back pain (CLBP) (45 years), and depression symptoms (45 and 50 years) from up to 9,377 participants in the 1958 British cohort. Depression symptom outcomes were derived by "Clinical Interview Schedule-Revised" (45 years) and "Short Form-36" (50 years). Relationships between both chronic pain conditions and depression symptoms were investigated by fitting four separate logistic regression models, each with varying levels of covariate adjustment, including depression at baseline. RESULTS: CWP was associated with depression symptoms cross-sectionally (odds ratio [OR] = 2.04, 95% confidence interval [CI] 1.65, 2.52; P < 0.001, n = 7,629), and prospectively when fully adjusted for baseline, sociodemographic, lifestyle, and health covariates (OR = 1.45, 95% CI 1.17, 1.80; P = < 0.001, n = 6,275). CLBP was associated with depression symptoms prospectively (full model: OR = 1.28, 95% CI 1.01, 1.61; P = 0.04, n = 6,288). In fully adjusted models the prospective association of CWP with depression symptoms was more heavily influenced by our covariates than CLBP with depression symptoms. CONCLUSION: Pain may be a stressor from which depression can arise. Development of depression may be differentially dependant upon the type of pain experienced. Screening for depression symptoms among individuals with both chronic pain conditions is indicated and should be repeated over time.

Increase of Human Milk Fat Inducing Nutritional Ketosis in Exclusively Breastfed Infant, Brought About by Treating the Mother With Ketogenic Dietary Therapy.

INTRODUCTION: Medicalized Ketogenic Therapy is commonly used to treat refractory epilepsy. Patients have varying degrees of seizure or symptom relief, responding at individual levels of ketone production. Typically, initiating the therapy necessitates the discontinuation of breastfeeding. Our case study mother was keen to continue breastfeeding if possible. We were able to achieve this by placing the healthy mother on a ketogenic diet and altering the composition of the mother's own milk. MAIN LACTATION ISSUE: Pediatric Medicalized Ketogenic Therapy is delivered through a ketogenic diet consisting of up to 90% fat, measuring of ingredients to 0.1 g matching a food prescription of fat, protein, and carbohydrate. We placed the mother on a less stringent ketogenic diet achieving 61% fat and measured both infant and mother's blood sugar levels and ketones. The hypothesis was that changes would occur in the mother's own milk fat content, and/or ketones would be passed directly to the infant. If therapeutic levels of ketones were reached in the infant and a reduction in seizures observed, breastfeeding could continue. MANAGEMENT OVERVIEW: Over 3 months we achieved a calorific increase of the mother's mature milk by an additional 134%. The infant was successfully put into nutritional ketosis and visible seizures eliminated. CONCLUSION: Medicalized Ketogenic Therapy can be safely used to treat seizures of breastfeeding infants diagnosed with epilepsy, through management of the mother on a ketogenic diet. Significantly increasing the mature mothers own milk fat component could have implications for other areas, including faltering growth.

Precision health: a primer for physiotherapists.

Health care provision is changing, and so is the information we use to guide decisions related to patient care. Increasingly, health practitioners will need to deal with genetics and 'big data' in the context of clinical practice. Indeed, commercial packages for consumer genetic testing are already widely available, and devices enabling self-monitoring of health are in daily use by many of our patients. "Precision health" (distinct from "precision medicine") provides a model, which allows us to bring our genome together with our external environment (lifestyles, societal influences etc.) and eventually, our transient internal environment (reflected by 'omics'), to optimise disease prevention and care. Such advancements have given rise to a need for primary health care clinicians to understand basic genetic and precision health concepts. This editorial meets this need, serving as a primer by providing the following: an introduction to current primary health challenges; description of the key elements of the precision health model; an overview of basic genetic, and associated research concepts; a snapshot of some clinically pertinent research in the context of precision health; and a brief discussion of challenges and future directions.

Depression increases the genetic susceptibility to high body mass index: Evidence from UK Biobank.

BACKGROUND: This study aimed to explore the association between depression and body mass index (BMI), and to investigate whether genetic susceptibility to high BMI is different among individuals with or without depression. METHODS: We used data on 251,125 individuals of white British ancestry from the UK Biobank. We conducted Mendelian randomization (MR) analysis to test for a causal association between depression and BMI using a major depressive disorder (MDD)-related genetic risk score (GRSMDD ) as an instrument for depression. We also examined whether depression modifies genetic susceptibility to high BMI, by investigating the interaction between depression and the BMI-related GRSBMI . RESULTS: We found observational and genetic evidence for an association between depression and BMI (MR beta: 0.09, 95% confidence interval [CI] 0.04-0.13). Further, the contribution of genetic risk to high BMI was higher among individuals with depression compared to controls. Carrying 10 additional BMI increasing alleles was associated with 0.24 standard deviation (SD; 95%CI 0.23-0.25) higher BMI among depressed individuals compared to 0.20 SD (95%CI 0.19-0.21) higher in controls, which corresponds to 3.4 kg and 2.8 kg extra weight for an individual of average height. Amongst the individual loci, the evidence for interaction was most notable for a variant near MC4R, a gene known to affect both appetite regulation and the hypothalamic-pituitary adrenal axis (pinteraction = 5.7 × 10-5 ). CONCLUSION: Genetic predisposition to high BMI was higher among depressed than to nondepressed individuals. This study provides support for a possible role of MC4R in the link between depression and obesity.