The Test-retest Reliability of Pain Outcome Measures in People with Phantom Limb Pain.

OBJECTIVES: To quantify the test-retest reliability of three patient-reported outcome measures of pain for people living with phantom limb pain (PLP) and assess impact of test-retest errors on future research and clinical decisions. METHODS: Thirty-nine participants (30 males), mean (SD) age: 55 (16), mean (SD) years post amputation: 6.8 (8.3), reported their PLP levels on a Visual Analogue Scale (VAS) for pain intensity, the revised Short Form McGill Pain Questionnaire (SF-MPQ-2), and a pain diary, on two occasions 7-14 days apart. Mean systematic change, within-subjects SD, limits of agreement (LOA), coefficient of variation and the intraclass correlation coefficient (ICC) were quantified alongside their respective 95% confidence intervals (95%CI). RESULTS: Systematic learning effects (mean changes) were not clinically relevant across the VAS, SF-MPQ-2 and pain diary. Within-subjects SDs (95%CI) were 11.8 (9.6-15.3), 0.9 (0.7-1.2), and 8.6 (6.9-11.5), respectively. LOA (95%CI) were 32.6 (26.5-42.4), 2.5 (2-3.3), and 23.9 (19.2-31.8), respectively. ICCs (95%CI) were 0.8 (0.6-0.9), 0.8 (0.7-0.9), and 0.9 (0.8-0.9), respectively, but may have been inflated by sample heterogeneity. The test-retest errors allowed detection of clinically relevant effect sizes with feasible sample sizes in future studies, but individual errors were large. DISCUSSION: For people with PLP, a pain intensity VAS, the SF-MPQ-2, and a pain diary show an acceptable level of inter-session reliability for use in future clinical trials with feasible sample sizes. Nevertheless, the random error observed for all three of the pain outcome measures suggests they should be interpreted with caution in case studies and when monitoring individuals' clinical status and progress.

Acceptability and feasibility of virtual reality to promote health literacy in primary care from the health professional's view: A qualitative study.

OBJECTIVE: The development of health literacy is important in the management of chronic pain and virtual reality may be an effective medium for its development. This study aims to understand the usability and acceptability of a virtual reality-based pain education system for the facilitation of health literacy. METHODS: Semi-structured interviews were conducted with health professionals who had used a VR-based pain education system within their clinical practice, to explore perceptions of feasibility. Data collection and analyses were informed by the Unified Theory of Acceptance and Use of Technology and the Integrated Model of Health Literacy. RESULTS: From 10 participants, the VR-based system was considered feasible in providing immersive experiential learning which addressed patient understanding and health-related communication. CONCLUSION: VR appears to be perceived as an acceptable and feasible technology to support the development of health literacy in people with chronic pain. Its largest perceived benefit was its capacity to provide an immersive and entertaining alternative to conventional methods of pain education. PRACTICE IMPLICATIONS: Virtual reality is considered as a feasible method of facilitating patient understanding and health-related communication related to chronic pain. Feasibility of such a tool relies clinically on time available, social expectations of VR, and the role of immersive and experiential learning within the management of chronic pain.

We Are All in This Together-Whole of Community Pain Science Education Campaigns to Promote Better Management of Persistent Pain.

Persistent pain is a major public health issue-estimated to affect a quarter of the world's population. Public understanding of persistent pain is based on outdated biomedical models, laden with misconceptions that are contrary to best evidence. This understanding is a barrier to effective pain management. Thus, there have been calls for public health-based interventions to address these misconceptions. Previous pain-focussed public education campaigns have targeted pain beliefs and behaviours that are thought to promote recovery, such as staying active. However, prevailing pain-related misconceptions render many of these approaches counter-intuitive, at best. Pain Science Education improves understanding of 'how pain works' and has been demonstrated to improve pain and disability outcomes. Extending Pain Science Education beyond the clinic to the wider community seems warranted. Learning from previous back pain-focussed and other public health educational campaigns could optimise the potential benefit of such a Pain Science Education campaign. Pain Science Education-grounded campaigns have been delivered in Australia and the UK and show promise, but robust evaluations are needed before any firm conclusions on their population impact can be made. Several challenges exist going forward. Not least is the need to ensure all stakeholders are involved in the development and implementation of Pain Science Education public messaging campaigns. Furthermore, it is crucial that campaigns are undertaken through a health equity lens, incorporating underrepresented communities to ensure that any intervention does not widen existing health inequalities associated with persistent pain. PERSPECTIVE: Public misconceptions about pain are a significant public health challenge and a viable intervention target to reduce the personal, social, and economic burden of persistent pain. Adaptation of Pain Science Education, which improves misconceptions in a clinical setting, into the public health setting seems a promising approach to explore.

Teaching Patients About Pain: The Emergence of Pain Science Education, its Learning Frameworks and Delivery Strategies.

Since it emerged in the early 2000's, intensive education about 'how pain works', widely known as pain neuroscience education or explaining pain, has evolved into a new educational approach, with new content and new strategies. The substantial differences from the original have led the PETAL collaboration to call the current iteration 'Pain Science Education'. This review presents a brief historical context for Pain Science Education, the clinical trials, consumer perspective, and real-world clinical data that have pushed the field to update both content and method. We describe the key role of educational psychology in driving this change, the central role of constructivism, and the constructivist learning frameworks around which Pain Science Education is now planned and delivered. We integrate terminology and concepts from the learning frameworks currently being used across the PETAL collaboration in both research and practice-the Interactive, Constructive, Active, Passive framework, transformative learning theory, and dynamic model of conceptual change. We then discuss strategies that are being used to enhance learning within clinical encounters, which focus on the skill, will, and thrill of learning. Finally, we provide practical examples of these strategies so as to assist the reader to drive their own patient pain education offerings towards more effective learning. PERSPECTIVE: Rapid progress in several fields and research groups has led to the emergence 'Pain Science Education'. This PETAL review describes challenges that have spurred the field forward, the learning frameworks and educational strategies that are addressing those challenges, and some easy wins to implement and mistakes to avoid.

Perspectives on the insidious nature of pain metaphor: we literally need to change our metaphors.

Metaphorical language is used to convey one thing as representative or symbolic of something else. Metaphor is used in figurative language but is much more than a means of delivering "poetic imagination". A metaphor is a conceptual tool for categorising, organizing, thinking about, and ultimately shaping reality. Thus, metaphor underpins the way humans think. Our viewpoint is that metaphorical thought and communication contribute to "painogenicity", the tendency of socio-ecological environments (settings) to promote the persistence of pain. In this perspectives article, we explore the insidious nature of metaphor used in pain language and conceptual models of pain. We explain how metaphor shapes mental organisation to govern the way humans perceive, navigate and gain insight into the nature of the world, i.e., creating experience. We explain how people use metaphors to "project" their private sensations, feelings, and thoughts onto objects and events in the external world. This helps people to understand their pain and promotes sharing of pain experience with others, including health care professionals. We explore the insidious nature of "warmongering" and damage-based metaphors in daily parlance and demonstrate how this is detrimental to health and wellbeing. We explore how metaphors shape the development and communication of complex, abstract ideas, theories, and models and how scientific understanding of pain is metaphorical in nature. We argue that overly simplistic neuro-mechanistic metaphors of pain contribute to fallacies and misnomers and an unhealthy focus on biomedical research, in the hope of developing medical interventions that "prevent pain transmission [sic]". We advocate reconfiguring pain language towards constructive metaphors that foster a salutogenic view of pain, focusing on health and well-being. We advocate reconfiguring metaphors to align with contemporary pain science, to encourage acceptance of non-medicalised strategies to aid health and well-being. We explore the role of enactive metaphors to facilitate reconfiguration. We conclude that being cognisant of the pervasive nature of metaphors will assist progress toward a more coherent conceptual understanding of pain and the use of healthier pain language. We hope our article catalyses debate and reflection.

The Association of Pain with Incident Falls in People with Chronic Obstructive Pulmonary Disease: Evidence from the English Longitudinal Study of Ageing.

People with chronic obstructive pulmonary disease (COPD) have a higher prevalence of pain and a greater risk of falls than their healthy peers. As pain has been associated with an increased risk of falls in older adults, this study investigated the association between pain and falls in people with COPD compared to healthy controls. Data from the English Longitudinal Study of Ageing were used to establish an association between pain and falls when modelled with a generalised ordinal logistic regression and adjusted for sex, age, wealth, and education (complete case analysis only; n = 806 COPD, n = 3898 healthy controls). The odds were then converted to the predicted probabilities of falling. The predicted probability of falling for people with COPD was greater across all pain categories than for healthy controls; for COPD with (predicted probability % [95%CI]), no pain was 20% [17 to 25], with mild pain was 28% [18 to 38], with moderate pain was 28% [22 to 34] with severe pain was 39% [30 to 47] and for healthy controls with no pain was 17% [16 to 18], mild pain 22% [18 to 27], moderate pain 25% [20 to 29] and severe pain 27% [20 to 35]. The probability of falling increased across pain categories in individuals with COPD, with the most severe pain category at a nearly 40% probability of falling, indicating a potential interaction between COPD and pain.

Global and regional estimates of clinical and economic burden of low back pain in high-income countries: a systematic review and meta-analysis.

Introduction: Low back pain (LBP) is a common health problem, and the leading cause of activity limitation and work absence among people of all ages and socioeconomic strata. This study aimed to analyse the clinical and economic burden of LBP in high income countries (HICs) via systematic review and meta-analysis. Methods: A literature search was carried out on PubMed, Medline, CINAHL, PsycINFO, AMED, and Scopus databases was from inception to March 15th, 2023. Studies that assessed the clinical and economic burden of LBP in HICs and published in English language were reviewed. The methodological quality of the included studies was assessed using the Newcastle-Ottawa quality assessment scale (NOS) for cohort studies. Two reviewers, using a predefined data extraction form, independently extracted data. Meta-analyses were conducted for clinical and economic outcomes. Results: The search identified 4,081 potentially relevant articles. Twenty-one studies that met the eligibility criteria were included and reviewed in this systematic review and meta-analysis. The included studies were from the regions of America (n = 5); Europe (n = 12), and the Western Pacific (n = 4). The average annual direct and indirect costs estimate per population for LBP ranged from € 2.3 billion to € 2.6 billion; and € 0.24 billion to $8.15 billion, respectively. In the random effects meta-analysis, the pooled annual rate of hospitalization for LBP was 3.2% (95% confidence interval 0.6%-5.7%). The pooled direct costs and total costs of LBP per patients were USD 9,231 (95% confidence interval -7,126.71-25,588.9) and USD 10,143.1 (95% confidence interval 6,083.59-14,202.6), respectively. Discussion: Low back pain led to high clinical and economic burden in HICs that varied significantly across the geographical contexts. The results of our analysis can be used by clinicians, and policymakers to better allocate resources for prevention and management strategies for LBP to improve health outcomes and reduce the substantial burden associated with the condition. Systematic review registration: https://www.crd.york.ac.uk/prospero/#recordDetails?, PROSPERO [CRD42020196335].

Digitally deployed, GP remote consultation video intervention that aims to reduce opioid prescribing in primary care: protocol for a mixed-methods evaluation.

INTRODUCTION: Opioid prescribing rates are disproportionately high in the North of England. In addition to patients' complex health needs, clinician prescribing behaviour is also a key driver. Although strategies have been initiated to reduce opioid prescribing nationally, the COVID-19 pandemic has interrupted service provision and created challenges for the system and health professionals to tackle this complex issue. A pilot intervention using smartphone video messaging has been developed to remotely explain the rationale for opioid reduction and facilitate self-initiation of support. The aim of this study is to evaluate the potential benefits, risks and economic consequences of 'at scale' implementation. METHODS AND ANALYSIS: This will be a mixed-methods study comprising a quasi-experimental non-randomised before-and-after study and qualitative interviews. The intervention arm will comprise 50 General Practitioner (GP) Practices using System 1 (a clinical computer system hosting the intervention) who will deliver the video to their patients via text message. The control arm will comprise 50 practices using EMIS (a different computer system) who will continue usual care. Monthly practice level prescribing and consultation data will be observed for 6 months postintervention. A general linear model will be used to estimate the association between the exposure and the main outcome (opioid prescribing; average daily quantity (ADQ)/1000 specific therapeutic group age-sex related prescribing unit). Semi-structured interviews will be undertaken remotely with purposively selected participants including patients who received the video, and health professionals involved in sending out the videos and providing additional support. Interviews will be audio recorded, transcribed and analysed thematically. ETHICS AND DISSEMINATION: Ethics approval has been granted by the NHS Health Research Authority Research Ethics Committee (22/PR/0296). Findings will be disseminated to the participating sites, participants, and commissioners, and in peer-reviewed journals and academic conferences. TRIAL REGISTRATION NUMBER: NCT05276089.

Low test-retest reliability of a protocol for assessing somatosensory cortex excitability generated from sensory nerves of the lower back.

In people with chronic low back pain (CLBP), maladaptive structural and functional changes on a cortical level have been identified. On a functional level, somatosensory cortical excitability has been shown to be reduced in chronic pain conditions, resulting in cortical disinhibition. The occurrence of structural and/or functional maladaptive cortical changes in people with CLBP could play a role in maintaining the pain. There is currently no measurement protocol for cortical excitability that employs stimulation directly to the lower back. We developed a protocol for the measurement of single pulse somatosensory evoked potential (SEP) waveforms and paired-pulse behavior (PPB) generated from sensory nerves of the lower back and quantified its test-retest reliability in a sample of 30 healthy individuals to gain insights into the normal variability of cortical responses, which could then be compared to results from people with CLBP. We investigated cortical excitability by measuring SEPs and PPB. PPB was defined as the ratio of the amplitude of the second cortical response (A2s) divided by the first cortical response (A1). A2s was determined by subtracting the response to single-pulse stimuli from the paired pulse stimuli response to account for linear superposition effects. The test-retest reliability of the protocol was very poor with no evidence of systematic bias but a high amount of random variability between sessions. There was no significant difference in the right side PPB for session 1 (Mean ratio A2s/A1 = 0.66, SD = 0.54) and session 2 (Mean ratio A2s/A1 = 0.94, SD = 1.56); mean session difference [(95% CI) = -0.44 (-1.23 to 0.34); t (22) = -1.17, p = 0.26]. The ICC3.1 (absolute agreement) for the outlier-removed right side PPB were 0.19 (95% CI: -0.84 to 0.66) and 0.43 for left side PPB (95% CI: -0.37 to 0.76). This finding potentially has wider implications for PPB protocols. If these findings were replicated in other groups and other nerves, it would question the validity of this measure more generally. However, these findings are restricted to healthy people and sensory nerves of the lower back and may not be generalizable.

International, multi-disciplinary, cross-section study of pain knowledge and attitudes in nursing, midwifery and allied health professions students.

BACKGROUND: Persistent pain is a highly prevalent, global cause of disability. Research suggests that many healthcare professionals are not well equipped to manage pain, and this may be attributable at least in part to undergraduate education. The primary aim of this study was to quantify and compare first and final year nursing, midwifery and allied health professional (NMAHP) students' pain related knowledge and attitudes. The secondary aim was to explore what factors influence students' pain related knowledge and attitudes. METHODS: In this cross-sectional study, 1154 first and final year healthcare students, from 12 universities in five different countries completed the Revised Neurophysiology of Pain Quiz (RNPQ) [knowledge] and the Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS) [attitudes]. RESULTS: Physiotherapy was the only student group with statistically and clinically improved pain related knowledge [mean difference, 95% CI] (3.4, 3.0 to 3.9, p = 0.01) and attitudes (-17.2, -19.2 to 15.2, p = 0.01) between first and final year. Pain education teaching varied considerably from course to course (0 to 40 h), with greater levels of pain related knowledge and attitudes associated with higher volumes of pain specific teaching. CONCLUSIONS: There was little difference in pain knowledge and attitudes between all first and final year NMAHP students other than physiotherapy. This suggests that for most NMAHP disciplines, undergraduate teaching has little or no impact on students' understanding of pain. There is an urgent need to enhance pain education provision at the undergraduate level in NMAHPs. TRIAL REGISTRATION: The study protocol was prospectively registered at ClinicalTrials.Gov NCT03522857 .

An exploration of primary care healthcare professionals' understanding of pain and pain management following a brief pain science education.

BACKGROUND: Persistent pain is a leading cause of disability worldwide yet implementation of clinical guidelines that recommend a biopsychosocial approach remains a challenge in clinical practise. Limited pain understanding amongst clinicians may be partly responsible for this. PURPOSE OF THE STUDY: 1) Qualitatively explore the experience of receiving PSE, understanding of PSE and operationalisation of PSE-related principles in routine clinical practice. 2) Quantitatively explore pain knowledge, attitudes, and behaviours of general practitioners (GPs) and nurse practitioners (NPs) before and after pain science education (PSE). METHODS: An exploratory, single-site, mixed-methods study in north-east England. Fifteen NPs/GPs completed questionnaires and a case-vignette before and after a 70-min face-to-face PSE lecture. Qualitative data were thematically analysed from two focus groups after the intervention. RESULTS: Clinicians' relatively high prior levels of knowledge, attitudes, and behaviour were similar after PSE. Qualitative themes described facilitation of self-reflection on pain management behaviours, and difficulties in operationalising PSE principles in practise including: limited patient rapport; short appointment times; patients' passive and often oppositional biomedical treatment expectations; and clinicians' lack of readily understandable language to communicate with patients. CONCLUSION: The findings highlight the value of PSE perceived by these clinicians who were already favourably inclined towards biopsychosocial pain management. They sought more resources for their personal learning and for communication with patients. Even with such favourable disposition, the practicalities and environment of clinical practice impeded the operationalisation of PSE-related principles. TRIAL REGISTRATION: This study was prospectively registered at ClinicalTrials.Gov ( NCT04587596 ) in October 2020.

Sensory discrimination training for adults with chronic musculoskeletal pain: a systematic review.

BACKGROUND: Sensory discrimination training (SDT) is a form of feedback guided sensory training used in the treatment of chronic musculoskeletal pain (CMP). OBJECTIVE: This systematic review aimed to investigate the efficacy and safety of SDT for CMP. METHODS: MEDLINE, CINAHL, EMBASE, AMED, CENTRAL, PsycINFO, Scopus, OT Seeker, PEDro, ETHOS, Web of Science, and Open Grey were searched for appropriate randomized controlled trials (RCTs). Included papers were assessed for risk of bias, and evidence was graded using the GRADE approach. The protocol was published on PROSPERO (anonymized). RESULTS: Ten RCTs met the inclusion/exclusion criteria. There was conflicting evidence from seven RCTs for the efficacy of SDT for chronic low back pain (CLBP). There was very low-quality evidence from two studies supporting the efficacy of SDT for phantom limb pain (PLP). There was very low-quality evidence from one RCT for the efficacy of SDT for Fibromyalgia. No adverse effects of SDT were identified. CONCLUSIONS: SDT has been delivered in multiple forms in the literature. SDT does not appear to be associated with any adverse effects and shows potential regarding its clinical efficacy. However, there is a lack of high-quality evidence upon which to make any firm clinical recommendations.

Charting physiotherapy students' attitudes toward people with chronic pain as they progress through their undergraduate programme: An observational study.

BACKGROUND: Healthcare professionals' attitudes toward people with chronic pain influence their clinical practice. OBJECTIVES: To investigate physiotherapy students' attitudes and beliefs toward people with chronic pain over the course of their Scottish undergraduate program. METHODS: In this observational study, physiotherapy students from one university were recruited in the first year and followed up to their final year (year 1 n = 62/75, year 2 n = 68/72, year 3 n = 59/69, year 4 n = 74/74) for 4 years. The Health-Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS with scores ranging from 15 to 105) was completed annually. RESULTS: A one-way ANOVA found that attitudes and beliefs improved significantly (p < .01) from the first to final year (9.2 ± 11.5 (mean±SD)). Participants showed a reduction in scores (signifying improved attitudes) annually with smaller reductions initially followed by a larger reduction in the final 2 years. CONCLUSIONS: This is the first study to chart changes in the same cohort of physiotherapy students' attitudes and beliefs toward people with chronic pain over time. Future work should explore which aspects of degree courses, if any, impact upon attitudes and beliefs toward people with chronic pain so that courses can be enhanced accordingly.

Long-term improvements following a residential combined physical and psychological programme for chronic low back pain.

OBJECTIVES: Evaluate the outcomes and explore experiences of patients undergoing a residential combined physical and psychological programme (CPPP) for chronic low back pain. DESIGN: A longitudinal observational cohort design, with a parallel qualitative design using semistructured interviews. SETTING: Residential, multimodal rehabilitation. PARTICIPANTS: 136 adults (62 male/74 female) referred to the CPPP, 100 (44 male/56 female) of whom completed the programme, during the term of the study. Ten (2 male/8 female) participated in the qualitative evaluation. INTERVENTION: A 3-week residential CPPP. OUTCOME MEASURES: Primary outcome measures were the STarT Back screening tool score; pain intensity-11-point Numerical Rating Scale; function-Oswestry Disability Index (ODI); health status/quality of life-EQ-5D-5L EuroQol five-Dimension-five level; anxiety-Generalised Anxiety Disorder-7; depression-Patient Health Questionnaire-9. Secondary outcome measures were the Global Subjective Outcome Scale; National Health Service Friends and Family Test;. RESULTS: At discharge, 6 and 12 months follow ups, there were improvements from baseline that were greater than minimum clinically important differences in each of the outcomes (with the sole exception of ODI at discharge). At 12 months, the majority of people considered themselves a lot better (57%) and were extremely likely (86%) to recommend the programme to a friend. The qualitative data showed praise for the residential nature of the intervention and the opportunities for interaction with peers and peer support. There were testimonies of improvements in understanding of pain and how to manage it better. Some participants said they had reduced, or stopped, medication they had been taking to manage their pain. CONCLUSIONS: Participants improved, and maintained long term, beyond minimum clinically important differences on a wide range of outcomes. Participants reported an enhanced ability to self-manage their back pain and support for the residential setting.

Inter-Individual Differences in the Responses to Pain Neuroscience Education in Adults With Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Pain neuroscience education (PNE) is an approach used in the management of chronic musculoskeletal pain. Previous reviews on PNE and other pain interventions, have focused on mean treatment effects, but in the context of "precision medicine," any inter-individual differences in treatment response are also important to quantify. If inter-individual differences are present, and predictors identified, PNE could be tailored to certain people for optimizing effectiveness. Such heterogeneity can be quantified using recently formulated approaches for comparing the response variance between the treatment and control groups. Therefore, we conducted a systematic review and meta-analysis on the extracted standard deviations of baseline-to-follow up change to quantify the inter-individual variation in pain, disability and psychosocial outcomes in response to PNE. Electronic databases were searched between January 1, 2002 and June 14, 2018. The review included 5 randomized controlled trials (n = 428) in which disability outcomes were reported. Using a random effects meta-analysis, the pooled SD (95% confidence interval) for control group-adjusted response heterogeneity to PNE was 7.36 units /100 (95% confidence interval = -3.93 to 11.12). The 95% prediction interval for this response heterogeneity SD was wide (-10.20 to 14.57 units /100). The control group-adjusted proportion of "responders" in the population who would be estimated to exceed a clinically important change of 10/100 ranged from 18 to 45%. Therefore, when baseline-to-follow up random variability in disability is taken into account (informed by the control arm), there is currently insufficient evidence for the notion of clinically important inter-individual differences in disability responses to PNE in people with chronic musculoskeletal pain. The protocol was published on PROSPERO (CRD42017068436). PERSPECTIVE: We bring a novel method to pain science for calculating inter-individual differences in response to a treatment. This is conductedwithin the context of a systematic review and meta-analysis on PNE. We highlight how using erroneous methods for calculating inter-individual differences can drastically change conclusions when compared to appropriate methods.

Exercise treatment effect modifiers in persistent low back pain: an individual participant data meta-analysis of 3514 participants from 27 randomised controlled trials.

BACKGROUND: Low back pain is one of the leading causes of disability worldwide. Exercise therapy is widely recommended to treat persistent non-specific low back pain. While evidence suggests exercise is, on average, moderately effective, there remains uncertainty about which individuals might benefit the most from exercise. METHODS: In parallel with a Cochrane review update, we requested individual participant data (IPD) from high-quality randomised clinical trials of adults with our two primary outcomes of interest, pain and functional limitations, and calculated global recovery. We compiled a master data set including baseline participant characteristics, exercise and comparison characteristics, and outcomes at short-term, moderate-term and long-term follow-up. We conducted descriptive analyses and one-stage IPD meta-analysis using multilevel mixed-effects regression of the overall treatment effect and prespecified potential treatment effect modifiers. RESULTS: We received IPD for 27 trials (3514 participants). For studies included in this analysis, compared with no treatment/usual care, exercise therapy on average reduced pain (mean effect/100 (95% CI) -10.7 (-14.1 to -7.4)), a result compatible with a clinically important 20% smallest worthwhile effect. Exercise therapy reduced functional limitations with a clinically important 23% improvement (mean effect/100 (95% CI) -10.2 (-13.2 to -7.3)) at short-term follow-up. Not having heavy physical demands at work and medication use for low back pain were potential treatment effect modifiers-these were associated with superior exercise outcomes relative to non-exercise comparisons. Lower body mass index was also associated with better outcomes in exercise compared with no treatment/usual care. This study was limited by inconsistent availability and measurement of participant characteristics. CONCLUSIONS: This study provides potentially useful information to help treat patients and design future studies of exercise interventions that are better matched to specific subgroups. PROTOCOL PUBLICATION: https://doi.org/10.1186/2046-4053-1-64.

Exploring the origin of low back pain sub-classification: a scoping review protocol.

OBJECTIVE: This scoping review aims to map the different working definitions currently being used for the duration of acute, subacute and chronic low back pain (LBP), and to establish where these definitions originated and the rationale provided for the timeframes used. INTRODUCTION: Low back pain is a major social and economic problem worldwide. One of the most commonly used approaches to classify and manage patients with LBP is the traditional duration-based classification (acute, subacute and chronic). There are significant differences between studies in the timeframes used for what constitutes acute, subacute and chronic LBP. These discrepancies lead to heterogeneity in study results, making it difficult to compare or summarize findings. INCLUSION CRITERIA: Studies that include participants with non-specific LBP, regardless of sex, will be considered. Studies that include children or participants with specific causes of LBP will be excluded. METHODS: The following electronic databases will be searched: MEDLINE, Embase, CINAHL and PsycINFO. All types of studies will be included, provided they give a rationale for the definition of duration that they use. Studies will be limited to those published in English. Two independent reviewers will screen the retrieved articles against the eligibility criteria for the scoping review. A narrative synthesis will describe the definitions used in the study and the rationale given for the timeframes reported. This scoping review will give an insight into the background of the variation of timeframes used for duration-based classification of LBP.

Pain Neuroscience Education for Adults With Chronic Musculoskeletal Pain: A Mixed-Methods Systematic Review and Meta-Analysis.

Chronic musculoskeletal pain (CMP) is an urgent global public health concern. Pain neuroscience education (PNE) is an intervention used in the management of CMP aiming to reconceptualize an individual's understanding of their pain as less threatening. This mixed-methods review undertook a segregated synthesis of quantitative and qualitative studies to investigate the clinical effectiveness, and patients' experience of, PNE for people with CMP. Electronic databases were searched for studies published between January 1, 2002, and June 14, 2018. Twelve randomized, controlled trials (n = 755 participants) that reported pain, disability, and psychosocial outcomes and 4 qualitative studies (n = 50 participants) that explored patients experience of PNE were included. The meta-analyzed pooled treatment effects for PNE versus control had low clinical relevance in the short term for pain (-5.91/100; 95% confidence interval [CI], -13.75 to 1.93) and disability (-4.09/100; 95% CI, -7.72 to -.45) and in the medium term for pain (-6.27/100; 95% CI, -18.97 to 6.44) and disability (-8.14/100; 95% CI, -15.60 to -.68). The treatment effect of PNE for kinesiophobia was clinically relevant in the short term (-13.55/100; 95% CI, -25.89 to -1.21) and for pain catastrophizing in the medium term (-5.26/52; 95% CI, -10.59 to .08). A metasynthesis of 23 qualitative findings resulted in the identification of 2 synthesized findings that identified several key components important for enhancing the patient experience of PNE, such as allowing the patient to tell their own story. These components can enhance pain reconceptualization, which seems to be an important process to facilitate patients' ability to cope with their condition. The protocol was published on PROSPERO (CRD42017068436). Perspective: We outline the effectiveness of PNE for the management of pain, disability, and psychosocial outcomes in adults with CMP. Key components that can enhance the patient experience of PNE, such as allowing the patient to tell their own story, are also presented. These components may enhance pain reconceptualization.

Left/right limb judgement task performance following total knee replacement.

PURPOSE: Working body schema (WBS) of the limbs may be indirectly assessed using left/right limb judgement (LRLJ) task performance. This study aimed to investigate if: 1) Total Knee Replacement (TKR) patients perform LRLJ tasks with reference to their WBS; 2) patients have a disrupted WBS following a TKR for the replaced knee compared to the contralateral knee; and 3) lower limb-based LRLJ task performance changes following post-surgical rehabilitation using change in upper limb-based LRLJ task performance as a control. METHODS: In a convenience sample (n= 18, age 69 ± 7 yrs, 12F 6M) of TKR patients < 1 month post-surgery, WBS was assessed using LRLJ task performance for the upper (pictures of the hand) and lower limb (pictures of the foot) before and after rehabilitation. Accuracy and response time (RT) were analysed using a series of 2 × 2 × 2 ANOVAs. RESULTS: LRLJ task performance for images corresponding with the operated and non-operated side were comparable for accuracy (p= 0.83) and RT (p= 0.28). Accuracy for hand images was comparable from baseline to post-rehabilitation (p= 0.54) whereas accuracy for feet images increased significantly (p= 0.03). Responses for awkward posture images were significantly slower than for more natural posture images (p= 0.001). CONCLUSIONS: LRLJ task performance data reflected the typical biomechanical constraints indicative of implicit motor imagery being performed by patients. There was no evidence of a disrupted LRLJ task performance for the replaced knee compared to the contralateral knee. Following post-surgical rehabilitation, patients' lower limb LRLJ task performance improved whilst upper limb LRLJ task performance remained unchanged. These findings are the first to show that WBS improves with rehabilitation following TKR, and this may explain some of the clinical improvements observed. Undertaking LRLJ tasks could theoretically be a useful adjunct to current post-TKR rehabilitation.

An Exploration of the Experiences and Educational Needs of Patients With Failed Back Surgery Syndrome Receiving Spinal Cord Stimulation.

OBJECTIVE: To explore the experience of spinal cord stimulation (SCS) for patients with failed back surgery syndrome (FBSS). METHODS: Adults with FBSS referred for SCS underwent semistructured interviews at three time points: before their SCS trial, after the trial, and three months after receiving the SCS implant. The face-to-face interviews were audio recorded, transcribed verbatim and analyzed thematically. RESULTS: Twelve adults (8 male, 4 female, aged 38-80 years, pain duration 1-26 years) were recruited. Six themes were identified; 1) What should I expect? 2) Varied outcomes, 3) Understanding pain and this new treatment, 4) Experiences of the SCS journey, 5) Getting used to the device, and 6) Finding out what I need to know. Participants' expectations were varied and the procedures were broadly viewed as minor surgery. Participants' expectations about SCS were not limited to pain relief and included reductions in medication, better sleep, and increased physical activity. Participants' understanding of pain and how SCS purports to work was limited. Throughout the process, practical challenges were identified such as the surgical wound management and battery recharging. Participants received information from multiple sources and identified a range of key information needs including a quick-start guide on how to operate the device and a list of dos and don'ts. CONCLUSIONS: Overall, participants' understanding of SCS was limited. The value participants placed on understanding of the process varied markedly. A list of practical informational needs has been identified. Bespoke, user-friendly, informational tools should be developed from this list to enhance the patient experience of SCS.