The biopsychosocial factors associated with development of chronic musculoskeletal pain. An umbrella review and meta-analysis of observational systematic reviews.

AIM: The aim of this umbrella review was to establish which biopsychosocial factors are associated with development of chronic musculoskeletal pain. METHODS: Ovid Medline, Embase, Web of Science Core Collection, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, PsycINFO, CINAHL, PEDro, PROSPERO, Google Scholar and grey literature were searched from database inception to 4th April 2023. Systematic reviews of observational prospective longitudinal studies, including populations with <3 months (not chronic) musculoskeletal pain, investigating biopsychosocial factors that contribute to development of chronic (>3 months) musculoskeletal pain. Two reviewers searched the literature, assessed risk of bias (Assessing the Methodological Quality of Systematic Reviews-2), and evaluated quality (Grading of Recommendations, Assessment, Development and Evaluation) to provide an overall statement on the certainty of evidence for each biopsychosocial factor. Data analysis was performed through random effects meta-analysis (including meta-analysis of meta-analyses where possible) and descriptive synthesis. RESULTS: 13 systematic reviews were included comprising 185 original research studies (n = 489,644 participants). Thirty-four biopsychosocial factors are associated with development of chronic musculoskeletal pain. Meta-analyses of odds and/or likelihood ratios were possible for 25 biopsychosocial factors. There is moderate certainty evidence that smoking (OR 1.24 [95%CI, 1.14-1.34), fear avoidance (LR+ 2.11 [95%CI, 1.59-2.8]; LR- 0.5 [95%CI, 0.35-0.71]) poorer support networks (OR 1.21 [95%CI, 1.14-1.29]), lower socioeconomic status (OR 2.0 [95%CI, 1.64-2.42]), and high levels of pain (OR 5.61 [95%CI, 3.74-8.43]) are associated with development of chronic musculoskeletal pain (all P<0.001). Remaining factors are of low or very low certainty evidence. CONCLUSIONS AND RELEVANCE: There is moderate certainty evidence that smoking, fear avoidance, poorer support networks, lower socioeconomic status, and high levels of pain are associated with development of chronic musculoskeletal pain. High risk of bias was evident in most included reviews; this highlights the need for higher quality systematic reviews.

Musculoskeletal symptoms in systemic lupus erythematosus patients and their impact on health-related quality of life.

OBJECTIVES: To evaluate the musculoskeletal (MSK) symptoms experienced by SLE patients and determine how those symptoms relate to their health-related quality of life (HRQoL). MATERIALS AND METHODS: This is a cross-sectional study that was carried out on 103 adult SLE patients. sociodemographic, clinical, and therapeutic data were recruited. They were asked to complete the following: Nordic Musculoskeletal, Short-Form McGill Pain, and Lupus QoL Questionnaires. RESULTS: The mean age was 30.81 ± 9.44 years. There was a total of 86 females and 17 males (F: M:5:1). Almost all the patients reported MSK symptoms (96.1%). The maximum number of patients reported pain in the right and left wrist and hand (64.1%, 63.1%, respectively). One-fourth (25.2%) described at least five bodily sites of MSK symptoms, while 70.9% had more than five sites of MSK symptoms. Most of the patients described the pain as discomforting (40.8%). Patients with MSK symptoms scored significantly worse in all domains. In addition, the QoL scores of patients with more than 5 body sites of MSK symptoms were significantly lower than those of patients with fewer than 5 sites of MSK symptoms. CONCLUSION: SLE patients have a high MSK burden, and MSK symptoms have a negative impact on HRQoL in these patients.

Incidence of sick leave and disability pension in adults with musculoskeletal pain and co-occurring long-term conditions: data from the Norwegian HUNT study and national registries.

BACKGROUND: Musculoskeletal pain is one of the leading causes of work productivity loss. Long-term conditions (LTCs) commonly occur alongside musculoskeletal pain. However, the incidence of sick leave and disability pension according to LTC status in people with musculoskeletal pain has not been previously described. METHODS: Working-age participants (20-65 years) with persistent musculoskeletal pain who participated in the HUNT3 Study (1995-97) were included. Twenty-five LTCs were classified into 8 LTC groups according to the International Classification of Diseases version 11. Data on sickness and disability benefits were obtained from the National Insurance Database and linked to the HUNT3 data using participants' personal identification number. Age-adjusted incidence rates (IRs) (per 10,000 person-years) and hazard ratios (HRs) of sick leave during 5-year follow-up and disability pension during ~ 25-year follow-up were estimated with 95% confidence intervals (CIs) and presented according to LTC status. RESULTS: Overall, 11,080 participants with musculoskeletal pain were included. Of those, 32% reported one LTC and 45% reported ≥ 2 LTCs. During the follow up period, 1,312 participants (12%) received disability pension due to musculoskeletal conditions. The IR of sick leave and disability pension due to musculoskeletal conditions increased with number of LTCs. Specifically, the IR of sick leave was 720 (95% CI 672 to 768) in participants without any LTCs and 968 (95% CI 927 to 1,009) if they had ≥ 2 LTCs. The IRs of disability pension were 87 (95% CI 75 to 98) and 167 (95% CI 154 to 179) among those with no LTCs and ≥ 2 LTCs, respectively. The incidence of sick leave and disability pension due to musculoskeletal conditions was largely similar across LTCs, although the incidence of disability pension was somewhat higher among people with sleep disorders (IR: 223, 95% CI 194 to 252). CONCLUSIONS: Among people with persistent musculoskeletal pain, the incidence of prematurely leaving the work force due to musculoskeletal conditions was twice as high for those with multiple LTCs compared to those without any LTCs. This was largely irrespective of the type of LTC, indicating that the number of LTCs are an important feature when evaluating work participation among people with musculoskeletal pain.

Considerations beyond spine pain: do different co-occurring lower body joint pains differentially influence physical function and quality of life ratings?

BACKGROUND: Patients seeking medical care for back pain often have coexisting painful joints and the effects of different combinations and number of coexisting pain sites (hip, knee, foot/ankle) to back pain on physical function domains and quality of life rating are not yet established. The purpose of this study was to determine the differences in functional outcomes and QOL among individuals with back pain who have concurrent additional pain sites or no pain sites. METHODS: Data from the Osteoarthritis Initiative (OAI) cohort were used for this cross-sectional analysis. Men and women aged 45-79 years with back pain were binned into nine groups by presence or not of coexisting hip, knee, ankle/foot pain and combinations of these sites (N = 1,642). Healthy controls reported no joint pain. Main outcomes included Knee Injury and Osteoarthritis Outcome score (KOOS; quality of life and function-sports-and-recreation), Western Ontario McMaster Universities Osteoarthritis Index (WOMAC; Activities of Daily Living, Pain), Medical Outcomes Short Form-12 (SF-12) Physical Component score, and self-reported function in last 7-30 days (lifting 25-pound objects, housework). 20-m and 400-m walk times and gait speed and repeated chair rise test times were collected. RESULTS: Compared to back pain alone, pain at all five sites was associated with 39%-86% worse KOOS, WOMAC, and SF-12 scores (p < .0001). Back-Hip and Back-Knee did not produce worse scores than Back pain alone, but Back-Hip-Knee and Back-Knee-Ankle/Foot did. The 20-m, 400-m walk, and repeated chair times were worse among individuals with pain at all five sites. Additional hip and knee sites to back pain, but not ankle/foot, worsened performance-based walk times and chair rise scores. CONCLUSIONS: The number and type of coexistent lower body musculoskeletal pain among patients with back pain may be associated with perceived and performance-based assessments. Management plans that efficiently simultaneously address back and additional coexistent pain sites may maximize treatment functional benefits, address patient functional goals in life and mitigate disability.

Physical therapy interventions for people experiencing homelessness to improve pain and self-perceived health status.

BACKGROUND: Homeless shelters have emerged as components of the social services network, playing an important role in providing health care to the homeless population. The aim of this study was to evaluate an individualized physical therapy intervention for people experiencing homelessness and to determine the relationship between self-perceived variables. METHODS: Pre and post study, setting at the "Santa y Real Hermandad de Nuestra Señora del Refugio y Piedad" homeless shelter in Zaragoza, Spain. Participants were people experiencing homelessness with musculoskeletal disorders who attended a physical therapy service at shelter facilities. A physical therapy program was implemented including health education, exercise and manual therapy, electrotherapy, thermotherapy and bandaging. Demographic variables (age and gender), nationality, employment situation, educational level, pain location, number of painful areas, feeling of loneliness (3-Item Loneliness Scale; values from 3 to 9), pain intensity (Numerical Pain Rating Scale [NPRS]; from 0 to 10) and self-perceived health (Clinical Global Impression [CGI]; from 1 to 7). RESULTS: Sixty-four homeless people (age of 46.4 ± 10.9 years) participated in the study. Musculoskeletal pain was reported by 98.4% of subjects, with moderate pain intensities (6.1), and 48.4% presenting with pain at multiple sites. Perceptions of loneliness were low (3.7 ± 2.5) and self-perceived health status was moderately ill (3.5 ± 1.7). Positive significant correlations were identified between pain intensity and self-perceived health. The average number of sessions was 1.5 (± 0.8), with manual therapy (35.6%) followed by health education (23.5%) being the most frequently used techniques. Both pain and self-perceived health improved after treatment, even following a brief intervention. CONCLUSIONS: This study demonstrates the potentially negative impact of untreated pain on the self-perceived health of homeless individuals with musculoskeletal disorders that should be targeted for consideration. The findings suggest that a paradigm shift in pain management, including a physical therapy service in shelters, is needed to address the rehabilitation demands of these individuals in a real-life context. This study was approved by the Aragon Ethics Committee (PI19/438) and performed according to the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) statement.

Pilot study of musculoskeletal pain in ophthalmologists following participation in a fifteen-minute online Iyengar yoga program.

Purpose: To evaluate the prevalence of musculoskeletal (MSK) complaints in ophthalmologists and to assess whether participation in an online Iyengar yoga video program improves the baseline pain scores and awareness of proper posture in the clinic and operating room. Methods: Ophthalmologists were recruited from online professional forums for this nonrandomized, prospective study. A pre-intervention survey, including demographics, office and procedure volumes, wellness activities, and baseline MSK pain scores, was completed. A fifteen-minute instructional video focusing on simple yoga poses for the neck, shoulder, and lower back created by one of the authors, who is both an ophthalmologist and a certified Iyengar yoga teacher, was provided to participants to complete three times weekly for a total of 4 weeks. A post-intervention survey collecting MSK pain scores and information about ergonomics and compliance was completed. Results: Fifty ophthalmologists completed the pre-intervention survey, of whom 49 (98%) reported at least 1 episode of MSK discomfort in the preceding year. Of those, discomfort was cervical in 36 (72%), in the shoulder(s) in 15 (29%), thoracic spinal in 23 (46%), lumbar spinal in 23 (46%), and centered in the wrist, hand, or finger in 22 (44%). Of the 50 ophthalmologists, 22 submitted the post-intervention surveys. The post-intervention pain scores were decreased compared to baseline for cervical spine (P < 0.01), shoulder (P < 0.01), thoracic spine (P < 0.01), lumbar spine (P < 0.01) and wrist, hand, or finger (P < 0.01). 20 respondents (91%) reported improved awareness of their posture in the clinic and operating room, and 19 (86%) felt that this awareness would decrease their MSK symptoms. Conclusions: Among our small group of survey respondents, a fifteen-minute Iyengar yoga video program specifically designed for ophthalmologists reduced MSK pain and improving awareness of proper ergonomics for practicing ophthalmologists.

Environmental and sociocultural factors are associated with pain-related brain structure among diverse individuals with chronic musculoskeletal pain: intersectional considerations.

Chronic musculoskeletal pain including knee osteoarthritis (OA) is a leading cause of disability worldwide. Previous research indicates ethnic-race groups differ in the pain and functional limitations experienced with knee OA. However, when socioenvironmental factors are included in analyses, group differences in pain and function wane. Pain-related brain structures are another area where ethnic-race group differences have been observed. Environmental and sociocultural factors e.g., income, education, experiences of discrimination, and social support influence brain structures. We investigate if environmental and sociocultural factors reduce previously observed ethnic-race group differences in pain-related brain structures. Data were analyzed from 147 self-identified non-Hispanic black (NHB) and non-Hispanic white (NHW), middle and older aged adults with knee pain in the past month. Information collected included health and pain history, environmental and sociocultural resources, and brain imaging. The NHB adults were younger and reported lower income and education compared to their NHW peers. In hierarchical multiple regression models, sociocultural and environmental factors explained 6-37% of the variance in pain-related brain regions. Self-identified ethnicity-race provided an additional 4-13% of explanatory value in the amygdala, hippocampus, insula, bilateral primary somatosensory cortex, and thalamus. In the rostral/caudal anterior cingulate and dorsolateral prefrontal cortex, self-identified ethnicity-race was not a predictor after accounting for environmental, sociocultural, and demographic factors. Findings help to disentangle and identify some of the factors contributing to ethnic-race group disparities in pain-related brain structures. Numerous arrays of environmental and sociocultural factors remain to be investigated. Further, the differing sociodemographic representation of our NHB and NHW participants highlights the role for intersectional considerations in future research.

The effect of commuting time on burnout: the mediation effect of musculoskeletal pain.

OBJECTIVES: This study explores the relationship among commuting, musculoskeletal (MS) pain, and burnout. METHODS: An observational and cross-sectional study was conducted at a medical university-affiliated hospital in Taichung, Taiwan in 2021. The two questionnaire was used and they included the Copenhagen Burnout Inventory (CBI) and the Nordic Musculoskeletal Questionnaire (NMQ). All participants were invited to complete the cross-sectional survey. A multiple linear regression was assessed correlations between commuting, MS pain, and burnout. RESULTS: After excluding those with missing data, 1,615 healthcare workers were deemed valid as research participants. In multiple linear regression, commuting time longer than 50 min was associated with personal burnout (PB) in the presence of adjusted confounders; however, long commuting time was not associated with work-related burnout (WB). Furthermore, the choice of commuting method did not affect PB or WB. Notably, both neck and shoulder pain (NBSP) and ankle pain (BAP) increase the risk of PB and WB. The mediation analysis demonstrated that NBSP is a mediating factor, increasing the level of PB and WB for commuting times longer than 50 min. CONCLUSIONS: Healthcare workers who commute for more than 50 min should be considered part of a high-risk group for burnout and musculoskeletal pain. They should also be provided with resources and programs focused on burnout prevention and MS pain relief.

Chest pain in pediatric patients in the emergency department- Presentation, risk factors and outcomes-A systematic review and meta-analysis.

OBJECTIVE: This study aimed to assess and determine the presentation, risk factors, and outcomes of pediatric patients who were admitted for cardiac-related chest pain. BACKGROUND: Although chest pain is common in children, most cases are due to non-cardiac etiology. The risk of misdiagnosis and the pressure of potentially adverse outcomes can lead to unnecessary diagnostic testing and overall poorer patient experiences. Additionally, this can lead to a depletion of resources that could be better allocated towards patients who are truly suffering from cardiac-related pathology. METHODS: This review was conducted per PRISMA guidelines. This systematic review used several databases including MEDLINE, Embase, Scopus, and Web of Science to obtain its articles for review. RESULTS: A total of 6,520 articles were identified, and 11 articles were included in the study. 2.5% of our study population was found to have cardiac-related chest pain (prevalence = 0.025, 95% CI [0.013, 0.038]). The most commonly reported location of pain was retrosternal chest pain. 97.5% of the study population had a non-cardiac cause of chest pain, with musculoskeletal pain being identified as the most common cause (prevalence = 0.357, 95% CI [0.202, 0.512]), followed by idiopathic (prevalence = 0.352, 95% CI [0.258, 0.446]) and then gastrointestinal causes (prevalence = 0.053, 95% CI [0.039, 0.067]). CONCLUSIONS: The overwhelming majority of pediatric chest pain cases stem from benign origins. This comprehensive analysis found musculoskeletal pain as the predominant culprit behind chest discomfort in children. Scrutinizing our study cohort revealed that retrosternal chest pain stands as the unequivocal epicenter of this affliction. Thorough evaluation of pediatric patients manifesting with chest pain is paramount for the delivery of unparalleled care, especially in the context of potential cardiac risks in the emergency department.

Chronic pain-mental health comorbidity and excess prevalence of health risk behaviours: a cross-sectional study.

BACKGROUND: Chronic musculoskeletal pain and anxiety/depression are significant public health problems. We hypothesised that adults with both conditions constitute a group at especially high risk of future cardiovascular health outcomes. AIM: To determine whether having comorbid chronic musculoskeletal pain and anxiety/depression is associated with the excess prevalence of selected known cardiovascular health risk behaviours. METHOD: A cross-sectional survey of adults aged 35+ years randomly sampled from 26 GP practice registers in West Midlands, England. Respondents were classified into four groups based on self-reported presence/absence of chronic musculoskeletal pain (pain present on most days for six months) and anxiety or depression (Hospital Anxiety and Depression Score 11+). Standardised binomial models were used to estimate standardised prevalence ratios and prevalence differences between the four groups in self-reported obesity, tobacco smoking, physical inactivity, and unhealthy alcohol consumption after controlling for age, sex, ethnicity, deprivation, employment status and educational attainment. The excess prevalence of each risk factor in the group with chronic musculoskeletal pain-anxiety/depression comorbidity was estimated. FINDINGS: Totally, 14 519 respondents were included, of whom 1329 (9%) reported comorbid chronic musculoskeletal pain-anxiety/depression, 3612 (25%) chronic musculoskeletal pain only, 964 (7%) anxiety or depression only, and 8614 (59%) neither. Those with comorbid chronic musculoskeletal pain-anxiety/depression had the highest crude prevalence of obesity (41%), smoking (16%) and physical inactivity (83%) but the lowest for unhealthy alcohol consumption (18%). After controlling for covariates, the standardised prevalence ratios and differences for the comorbid group compared with those with neither chronic musculoskeletal pain nor anxiety/depression were as follows: current smoking [1.86 (95% CI 1.58, 2.18); 6.8%], obesity [1.93 (1.76, 2.10); 18.9%], physical inactivity [1.21 (1.17, 1.24); 14.3%] and unhealthy alcohol consumption [0.81 (0.71, 0.92); -5.0%]. The standardised prevalences of smoking and obesity in the comorbid group exceeded those expected from simple additive interaction.

New opioid prescription claims and their clinical indications: results from health administrative data in Quebec, Canada, over 14 years.

OBJECTIVES: Describe new opioid prescription claims, their clinical indications and annual trends among opioid naïve adults covered by the Quebec's public drug insurance plan (QPDIP) for the fiscal years 2006/2007-2019/2020. DESIGN AND SETTING: A retrospective observational study was conducted using data collected between 2006/2007 and 2019/2020 within the Quebec Integrated Chronic Disease Surveillance System, a linkage administrative data. PARTICIPANTS: A cohort of opioid naïve adults and new opioid users was created for each study year (median number=2 263 380 and 168 183, respectively, over study period). INTERVENTION: No. MAIN OUTCOME MEASURE AND ANALYSES: A new opioid prescription was defined as the first opioid prescription claimed by an opioid naïve adult during a given fiscal year. The annual incidence proportion for each year was then calculated and standardised for age. A hierarchical algorithm was built to identify the most likely clinical indication for this prescription. Descriptive and trend analyses were performed. RESULTS: There was a 1.7% decrease of age-standardised annual incidence proportion during the study period, from 7.5% in 2006/2007 to 5.8% in 2019/2020. The decrease was highest after 2016/2017, reaching 5.5% annual percentage change. Median daily dose and days' supply decreased from 27 to 25 morphine milligram equivalent/day and from 5 to 4 days between 2006/2007 and 2019/2020, respectively. Between 2006/2007 and 2019/2020, these prescriptions' most likely clinical indications increased for cancer pain from 34% to 48%, for surgical pain from 31% to 36% and for dental pain from 9% to 11%. Inversely, the musculoskeletal pain decreased from 13% to 2%. There was good consistency between the clinical indications identified by the algorithm and prescriber's specialty or user's characteristics. CONCLUSIONS: New opioid prescription claims (incidence, dose and days' supply) decreased slightly over the last 14 years among QPDIP enrollees, especially after 2016/2017. Non-surgical and non-cancer pain became less common as their clinical indication.

Reliability and measurement error of exercise-induced hypoalgesia in pain-free adults and adults with musculoskeletal pain: A systematic review.

OBJECTIVES: We systematically reviewed the reliability and measurement error of exercise-induced hypoalgesia (EIH) in pain-free adults and in adults with musculoskeletal (MSK) pain. METHODS: We searched EMBASE, PUBMED, SCOPUS, CINAHL, and PSYCINFO from inception to November 2021 (updated in February 2024). In addition, manual searches of the grey literature were conducted in March 2022, September 2023, and February 2024. The inclusion criteria were as follows: adults - pain-free and with MSK pain - a single bout of exercise (any type) combined with experimental pre-post pain tests, and assessment of the reliability and/or measurement error of EIH. Two independent reviewers selected the studies, assessed their Risk of Bias (RoB) with the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) RoB tool, and graded the individual results (COSMIN modified Grading of Recommendations Assessment, Development, and Evaluation). RESULTS: We included five studies involving pain-free individuals (n = 168), which were deemed to have an overall "doubtful" RoB. No study including adults with MSK pain was found. The following ranges of parameters of reliability and measurement error of EIH were reported: intraclass correlation coefficients: 0-0.61; kappa: 0.01-0.46; standard error of measurement: 30.1-105 kPa and 10.4-21%; smallest detectable changes: 83.54-291.1 kPa and 28.83-58.21%. CONCLUSIONS: We concluded, with a very low level of certainty, that the reliability and measurement error of EIH is, in pain-free adults, respectively, "insufficient" and "indeterminate." Future studies should focus on people with MSK pain and could consider using tailored exercises, other test modalities than pressure pain threshold, rater/assessor blinding, and strict control of the sources of variations (e.g., participants' expectations).

Challenges of acute pain management in older patients.

Adequate management of acute pain in the older population is crucial. However, it is inherently complex because of multiple physiological changes that significantly impact both the pharmacokinetics and pharmacodynamics of medications. Current guidelines promote paracetamol as the first-line analgesic for acute pain in older adults, whereas opioids are advised cautiously for moderate to severe acute pain. However, opioids come with a significant array of side effects, which can be more pronounced in older individuals. Ketamine administered via intranasal (IN) and nebulised inhalation in the emergency department for managing acute pain in older patients shows promising potential for improving pain management and reducing opioid reliance Kampan, Thong-on, Sri-on (2024, Age Ageing, 53, afad255). Nebulised ketamine appears superior in terms of adverse event incidence. However, the adoption of IN or nebulised ketamine in older adult acute pain management remains unclear because of the lack of definitive conclusions and clear guidelines. Nevertheless, these modalities can be valuable options for patients where opioid analgesics are contraindicated or when intravenous morphine titration is impractical or contraindicated. Here, we review these concepts, the latest evidence and propose avenues for research.

Musculoskeletal pain affects the age of retirement and the risk of work cessation among older people.

OBJECTIVES: Many people with chronic pain cannot work, while working despite chronic pain is linked to absenteeism and presenteeism and a host of other deleterious effects. This disproportionately affects older adults, who are closer to retirement, while the exact relationship between pain and work cessation as well as retirement among older adults is not known. We explore longitudinally the relationship between chronic pain and the risk of ceasing work and entering retirement. METHODS: Data from 1156 individuals 50 years or older living in England taking part in the English Longitudinal Study of Ageing were used in this study. Cox proportional hazards regression analyses were used to examine the nature of the relationship between musculoskeletal pain and work cessation as well as retirement longitudinally over the course of fourteen years. RESULTS: Suffering from frequent musculoskeletal pain was associated with an increased risk of ceasing work and retiring at an earlier age, as did work dissatisfaction, higher perceived social status, female gender, and not receiving the recognition they felt they deserved in their job. Severity of depressive symptoms, psychosocial job demands, decision authority, and social support did not influence the age at which participants reported work cessation or retirement. CONCLUSIONS: Frequent musculoskeletal pain may increase the risk of earlier work exit and earlier retirement. Further research should establish the mechanisms and decision making involved in leaving the workforce in people with frequent musculoskeletal pain.

Talking in primary care (TIP): protocol for a cluster-randomised controlled trial in UK primary care to assess clinical and cost-effectiveness of communication skills e-learning for practitioners on patients' musculoskeletal pain and enablement.

INTRODUCTION: Effective communication can help optimise healthcare interactions and patient outcomes. However, few interventions have been tested clinically, subjected to cost-effectiveness analysis or are sufficiently brief and well-described for implementation in primary care. This paper presents the protocol for determining the effectiveness and cost-effectiveness of a rigorously developed brief eLearning tool, EMPathicO, among patients with and without musculoskeletal pain. METHODS AND ANALYSIS: A cluster randomised controlled trial in general practitioner (GP) surgeries in England and Wales serving patients from diverse geographic, socioeconomic and ethnic backgrounds. GP surgeries are randomised (1:1) to receive EMPathicO e-learning immediately, or at trial end. Eligible practitioners (eg, GPs, physiotherapists and nurse practitioners) are involved in managing primary care patients with musculoskeletal pain. Patient recruitment is managed by practice staff and researchers. Target recruitment is 840 adults with and 840 without musculoskeletal pain consulting face-to-face, by telephone or video. Patients complete web-based questionnaires at preconsultation baseline, 1 week and 1, 3 and 6 months later. There are two patient-reported primary outcomes: pain intensity and patient enablement. Cost-effectiveness is considered from the National Health Service and societal perspectives. Secondary and process measures include practitioner patterns of use of EMPathicO, practitioner-reported self-efficacy and intentions, patient-reported symptom severity, quality of life, satisfaction, perceptions of practitioner empathy and optimism, treatment expectancies, anxiety, depression and continuity of care. Purposive subsamples of patients, practitioners and practice staff take part in up to two qualitative, semistructured interviews. ETHICS APPROVAL AND DISSEMINATION: Approved by the South Central Hampshire B Research Ethics Committee on 1 July 2022 and the Health Research Authority and Health and Care Research Wales on 6 July 2022 (REC reference 22/SC/0145; IRAS project ID 312208). Results will be disseminated via peer-reviewed academic publications, conference presentations and patient and practitioner outlets. If successful, EMPathicO could quickly be made available at a low cost to primary care practices across the country. TRIAL REGISTRATION NUMBER: ISRCTN18010240.

The SelfSTarT intervention for low back pain patients presenting to first contact physiotherapists: A mixed methods service evaluation.

INTRODUCTION: Globally, back pain is the leading cause of years of disability. In the United Kingdom, over 20 million people live with musculoskeletal (MSK) pain, with low back pain being one of the most common causes. National strategies promote self-management and the use of digital technologies to empower populations. AIMS: To evaluate the uptake and impact of providing the SelfSTart approach (STarT Back and SelfBACK App) when delivered by a First Contact Physiotherapist (FCP) to people presenting with low back pain in primary care. METHODS: Patients presenting with a new episode of low back pain underwent routine assessment and completion of a STarT Back questionnaire. Patients with low/medium scores were offered the SelfBACK App. A control population was provided by the MIDAS-GP study. Patient Experience, outcome measures, healthcare utilisation and retention were captured through the app and clinical systems (EMIS). Interviews with five FCPs explored the experiences of using the SelfSTart approach. RESULTS: SelfSTarT was taken up by almost half (48%) of those to whom it was offered. Compared to MIDAS-GP, users were more likely to be younger, male, in work, and with higher health literacy. SelfSTarT users reported significant improved experiences relating to receiving an agreed care plan and receiving sufficient information. There were no significant differences in treatments offered. FCPs were positive about the app and felt it had value but wanted feedback on patient progress. They recognised that a digital solution would not be suitable for all. CONCLUSION: This approach offers an opportunity to empower and support self-management, using robustly evaluated digital technology.

Cost of chiropractic versus medical management of adults with spine-related musculoskeletal pain: a systematic review.

BACKGROUND: The cost of spine-related pain in the United States is estimated at $134.5 billion. Spinal pain patients have multiple options when choosing healthcare providers, resulting in variable costs. Escalation of costs occurs when downstream costs are added to episode costs of care. The purpose of this review was to compare costs of chiropractic and medical management of patients with spine-related pain. METHODS: A Medline search was conducted from inception through October 31, 2022, for cost data on U.S. adults treated for spine-related pain. The search included economic studies, randomized controlled trials and observational studies. All studies were independently evaluated for quality and risk of bias by 3 investigators and data extraction was performed by 3 investigators. RESULTS: The literature search found 2256 citations, of which 93 full-text articles were screened for eligibility. Forty-four studies were included in the review, including 26 cohort studies, 17 cost studies and 1 randomized controlled trial. All included studies were rated as high or acceptable quality. Spinal pain patients who consulted chiropractors as first providers needed fewer opioid prescriptions, surgeries, hospitalizations, emergency department visits, specialist referrals and injection procedures. CONCLUSION: Patients with spine-related musculoskeletal pain who consulted a chiropractor as their initial provider incurred substantially decreased downstream healthcare services and associated costs, resulting in lower overall healthcare costs compared with medical management. The included studies were limited to mostly retrospective cohorts of large databases. Given the consistency of outcomes reported, further investigation with higher-level designs is warranted.

Comparative Analysis of Psychophysiological Responses in Fibromyalgia Patients: Evaluating Neuromodulation Alone, Neuromodulation Combined with Virtual Reality, and Exercise Interventions.

BACKGROUND AND OBJECTIVES: Fibromyalgia, a chronic condition, manifests as widespread musculoskeletal pain, fatigue, sleep disturbances, autonomic and cognitive dysfunction, hypersensitivity to stimuli, and various somatic and psychiatric symptoms. This study, a controlled and randomized experiment, aimed to evaluate and compare the immediate effects of different treatments on fibromyalgia patients. MATERIALS AND METHODS: The treatments included the EXOPULSE Mollii suit, a combination of the EXOPULSE Mollii suit with a virtual reality (VR) protocol, and a physical exercise regimen. A cohort of 89 female fibromyalgia patients was randomly assigned to one of four groups: Control (n = 20), Suit only (n = 22), Suit combined with VR (n = 21), and Exercise (n = 26). RESULTS: This study found notable differences across the groups in several key parameters. In the Control group, significant changes were observed in Forced Expiratory Volume (FEV 1/FEV 6), the Numeric Rating Scale (NRS) for pain, Pressure Pain Threshold (PPT) at the epicondyle, cortical arousal levels, the 10 m up-and-go test, and in all measured variables related to temperature and muscle oxygenation. For the group using the suit alone, there were significant differences noted in the NRS, the chair stand test, palm temperature, and all muscle oxygenation parameters. The Suit + VR group showed significant changes in the NRS, PPT at the knee, handgrip strength test, the 10 m up-and-go test, one-leg balance test with the right leg, muscle oxygen saturation (SmO2), deoxygenated hemoglobin (HHb), and oxygenated hemoglobin (O2Hb). Finally, the Exercise group exhibited significant differences in FEV 1/FEV 6, chest perimeter difference, NRS, PPT at both the epicondyle and knee, cortical arousal, the chair stand test, the 10-m up-and-go test, and in SmO2, HHb, and O2Hb levels. CONCLUSIONS: combining neuromodulation with VR and targeted exercise regimens can effectively alleviate fibromyalgia symptoms, offering promising avenues for non-pharmacological management.

Musculoskeletal Pain, Physical Activity, Muscle Mass, and Mortality in Older Adults: Results from the Korean Longitudinal Study on Health and Aging (KLoSHA).

Background and objectives: Musculoskeletal (MSK) pain significantly impacts physical activity and quality of life in older adults, potentially influencing mortality. This study explored the relationship between MSK pain, physical activity, muscle mass, and mortality among older adults. Material and Methods: We studied 1000 participants in the Korean Longitudinal Study on Health and Aging (KLoSHA), a prospective, population-based cohort study of people aged 65 years or older. Survival status was tracked over a 5-year period. Correlations between low back pain (LBP), knee pain, regular exercise, appendicular skeletal muscle mass (ASM), and other variables were analyzed. Logistic regression analyses were used to identify independent risk factors for mortality. Results: Of the total participants, 829 (82.9%) survived over a 5-year period. Survivors tended to be younger, had a higher BMI, and were more active in regular exercise. In contrast, non-survivors exhibited a higher prevalence of both LBP and knee pain, along with increased instances of multiple MSK pains. Lower ASM correlated moderately with LBP and knee pain, whereas higher ASM was associated with regular exercise. There was a moderate correlation between LBP and knee pain, both of which were associated with a lack of regular exercise. Age, sex, ASM, and regular exercise were significant predictors, even though MSK pain itself did not directly predict all-cause mortality. Conclusions: This study demonstrated the independent association between ASM, regular exercise, and mortality. Although MSK pain did not directly correlate with all-cause mortality, the non-survivor group had higher levels of both single and multiple MSK pains. Recognizing the interplay of MSK pain, physical activity, and muscle mass for older adults, the research underscores the need for holistic strategies to enhance health outcomes in older individuals with MSK pain.

Opioids for Acute Musculoskeletal Pain: A Systematic Review with Meta-Analysis.

OBJECTIVE: To evaluate the efficacy of opioids for people with acute musculoskeletal pain against placebo. STUDY DESIGN: Systematic review and meta-analyses of randomised, placebo-controlled trials of opioid analgesics for acute musculoskeletal pain in any setting. The primary outcomes were pain and disability at the immediate timepoint (< 24 h). DATA SOURCES: Multiple databases were searched from their inception to February 22nd, 2023. DATA SYNTHESIS: Continuous outcomes were converted to a 0-100 scale. Dichotomous outcomes were presented as risk differences. Risk of bias and certainty of evidence was assessed. RESULTS: We located 17 trials (1 intravenous and 16 oral route of administration). For adults, high certainty evidence from 11 comparisons shows that oral opioids provide small benefits relative to placebo in the immediate term for pain (mean difference [MD] - 8.8 95% confidence interval [CI] - 12.0 to - 5.6). For disability, the difference is uncertain (MD - 6.2, 95% CI - 17.8 to 5.4). Opioid groups were at higher risk of adverse events (MD 14.3%, 95% CI 8.3-20.4%, very low certainty). There was moderate certainty evidence of a large effect of IV morphine on sciatica pain (MD -42.5, 95% CI - 49.9 to - 35.1, n = 197, 1 study). In paediatric populations, moderate certainty evidence from 3 trials shows that oral opioids probably do not provide benefit beyond that of placebo for pain (MD 6.1, 95% CI - 1.7 to 12.8) and there was no evidence for disability. There was low certainty evidence that there may be no difference in adverse events (MD 10.4%, 95% CI - 0.6 to 21.4%). DISCUSSION: Intravenous morphine likely offers benefits, but oral opioids may not provide clinically meaningful benefits. PROSPERO REGISTRATION: CRD42021249346.