Barefoot walking is beneficial for individuals with persistent plantar heel pain: A single-blind randomized controlled trial.

BACKGROUND: A lack of data exist about the effectiveness of active treatments for persistent plantar heel pain (PPHP). OBJECTIVES: To compare short-term functional and clinical effects of a 4-week barefoot or shod treadmill walking program for people with PPHP. METHODS: A single-blinded clinical trial randomized 52 participants with PPHP into either a barefoot walking group (BWG), or a shod walking group (SWG). All participants received therapeutic ultrasound. Outcomes were measured at baseline (t0), following 4 weeks of treatment (t1), and at 1-month follow-up (t2). The SF-36 functional questionnaire score was the main outcome. Secondary outcomes were self-reported and clinically-assessed pain provocation levels, pressure pain thresholds and pain tolerance. Treadmill walking time and speed were measured at t0 and t1; people also recorded the time spent walking each day in a diary. RESULTS: The BWG exhibited significant improvements in all SF-36 items (except "emotional well-being") (P < 0.05), whereas the SWG exhibited improvements only in "pain" and "health change" items (P = 0.0001; effect size 0.13-0.94). Greater improvements were observed in the BWG than the SWG for "physical function" (P = 0.019) and "role limitations due to physical health" items (P = 0.035). Both groups demonstrated significant improvements in pain, with greater improvements in the BWG (P = 0.0001; effect size 0.89). Only the BWG showed significant improvements in pain pressure thresholds (P < 0.05; effect size 0.70) and pain tolerance (P < 0.001; effect size 0.67). Both groups significantly increased their speed and time spent walking on the treadmill (BWG Δ=19.7 min and Δ=1.7 km/h; SWG Δ=16.7 min and Δ=1.1 km/h) and time outdoors (SWG ∆=38.2 min/week; BWG mean ∆=48.5 min/week) (P < 0.001). All clinical tests of pain were significantly less positive in the BWG at all time points (P < 0.05). CONCLUSIONS: Both walking programs benefited people with PPHP by alleviating pain and improving function and quality of life. Greater improvements were observed in the BWG than the SWG overall.

"Nociplastic Pain": A Challenge to Nosology and to Nociception.

The construct of "nociplastic pain" has met with divergent receptions. On the one hand it has been enthusiastically embraced, to the extent of conflation with central sensitization of nociception and the International Classification of Diseases 11th Revision (ICD-11) entity of "primary" pain, and the promulgation of "nociplastic pain syndromes." On the other hand, it has been rejected by those whose skepticism derives from the absence, by definition, of underlying activation of nociceptors. This article seeks to dissect these divergent views and search for reconciliation between them. One line of argument is that "nociplastic" pain, "primary" pain, and "central sensitisation of nociception" reflect different domains of inquiry and should not be conflated. "Nociplastic" pain emerges as a hypothesis that confers clinical legitimacy and utility; while that hypothesis needs a minor but important modification and continues to require testing, discipline in its usage is necessary. The other line of argument discovers an unexpected impasse: the construct of "nociplastic pain" describes a phenomenon that accords with the International Association for the Study of Pain definition of pain but occurs in the absence of nociception-as-currently-defined, thus challenging the definitional link between pain and tissue damage. The article offers a resolution of this impasse by suggesting that nociception-as-currently-defined be replaced by the resurrected concept of a nociceptive apparatus, activation of which is necessary but not sufficient for the experience of pain. One consequence would be to allow the assertions underpinning "nociplastic" to be tested empirically; another would be to relate the phenomenon of pain to a more biologically plausible basis than "actual" or "resemblance to" tissue damage. PERSPECTIVE: This article explores the major challenges posed by "nociplastic pain" to nosology and to nociception. While discipline in the clinical use of the construct is required, it also emerges that the main issue is the International Association for the Study of Pain definition of nociception. A reconceptualization of nociception is proposed for logical, biological, and clinical coherence.

Healthcare providers have insufficient up-to-date knowledge of lower limb sports injuries, and their knowledge is similar to that of athletes.

BACKGROUND: Being up-to-date with evidence-based knowledge of lower limb sports injuries is essential for Healthcare professionals (HCPs). PURPOSE: To assess whether HCPs possess up-to-date knowledge of lower limb sports injuries by comparing their knowledge to that of athletes. METHODS: With an expert panel, we developed an online quiz of 10 multiple-choice questions on various topics related to lower-limb sports injuries. Maximal score was 100. We used social media to invite HCPs (5 groups: Physiotherapists, Chiropractors, Medical Doctors, Trainers, and Other therapists) and athletes of all levels (amateur, semi-pro, and pro) to participate. We drafted the questions according to conclusions from the latest systematic reviews and meta-analyses. RESULTS: 1526 participants completed the study. Final quiz scores ranged from zero (n = 28, 1.8%) to 100 (n = 2, 0.1%) and were distributed normally with a mean score of 45.4 ± 20.6. None of the 6 groups' means surpassed the set threshold of 60 points. Multiple linear regressions of covariates indicated that age, gender, engagement in physical activity, learning hours per week, reading scientific journals, reading popular magazines and blogs, trainers, and other therapists' groups explained 19% of the variances (-5.914<ß < 15.082, 0.000

Lumbosacral zone features in individuals with nonspecific chronic low back pain are unique compared to controls and correlate with pain and dysfunction.

OBJECTIVES: To compare the lumbosacral nerve distances (LNDs) and sacroiliac joint (SIJ) morphology in individuals with nonspecific chronic low back pain (NSCLBP) and control and examine their correlations with pain and dysfunction in the former. MATERIALS AND METHODS: The sample includes 200 adult patients (ranging from 20 to 50 years old) referred for computerized abdominal tomography (CT): 100 individuals with NSCLBP (50 males and 50 females) and 100 individuals without NSCLBP (50 males and 50 females). CT scans were assessed for LNDs, degenerative sacroiliac changes, and joint bridging. Those factors were correlated to the outcomes of three self-reported questionnaires about pain and function (Oswestry, Fear-Avoidance, and Numerical Pain Rating Scale) in the NSCLBP group. RESULTS: Individuals with NSCLBP tend to have reduced LNDs from the sacral part of the SIJ compared to controls (males: right Δ = 5.8 mm, left Δ = 6.03 mm; females: right Δ = 7.9 mm, left Δ = 7.73 mm, two-way ANOVA, p < 0.01), with moderate significant negative correlations with all three questionnaires (-0.38 < Pearson's r < - 0.57, p < 0.02, i.e., reduced LNDs with greater disability and pain). The NSCLBP group had more significant SIJ degeneration severity that moderately correlated with two questionnaires (0.39 < Pearson's r < 0.66, p < 0.04, i.e., greater SIJ degeneration with greater disability and pain). In males, the existence of SIJ bridging strongly correlated with all three questionnaires (0.38 < Pearson's r < 0.78, p < 0.03), and in females, only the Fear-Avoidance Questionnaire and Numerical Pain Scale (0.29 < Pearson's r < 0.41, p < 0.04). CONCLUSION: Compared to controls, individuals with NSCLBP have reduced LNDs and worse SIJ degenerative changes that correlate with function and pain. KEY POINTS: • Individuals with nonspecific low back pain tend to have reduced lumbosacral nerve distances than healthy controls. This may be due to entrapments or inflammation of the nerves or surrounding tissues. • Individuals with nonspecific low back pain tend to have more severe degeneration of their sacroiliac joint than healthy controls. • The above findings significantly correlated with the scores of three self-reported questionnaires about pain and function, implicating that they may be of clinical significance.

The 'training load' construct: Why it is appropriate and scientific.

A recent paper called for the abandonment of the term load (and training load) when used outside its mechanical meaning, claiming it is "unscientific" and "breaches scientific principles." In this article, we explain why its use does not breach any scientific principles and we clarify the process of labelling, conceptualising and operationalising a construct. Training load is simply a label attributed to a higher-order construct overarching other interrelated sub-dimensions. This multi-level structure provides a framework (nomological network) to support the research process and also practical applications. Load is a word, and therefore cannot be "unscientific". The "use" or "misuse" of words and terms entirely depends upon definitions that should be based on current understanding. Misuse occurs when a term is decontextualised or interpreted according to a unilateral perspective. The field of mechanics does not have a monopoly on the term load (or other common terms such as work, stress and fatigue), which are legitimately used in many scientific areas and with various meanings. The 'obligation' to rely on terms abiding by the Système International d'Unités (SI) when describing a construct is inappropriate. The SI relates to how we can measure, not describe training load; i.e., SI is relevant to its operational and not its constitutive (descriptive) definition. Discussions regarding shared and standardised descriptions and definitions are more relevant than discussions about discarding terms in sport and exercise science. Researchers (and practitioners) can continue to use the term training load as it does not breach any scientific principles.

Pain is Not a "thing": How That Error Affects Language and Logic in Pain Medicine.

Effectiveness in academic and clinical communication depends upon agreement on what words and concepts denote and on the consequent ability to argue logically and accurately. In the pain medicine literature there are many examples of imprecision and confusion in this respect, including misnomers and fallacies in reasoning. This article firstly critically examines some of these misnomers. Identified themes include pain being conceptualised as a "thing," conflation between nociception and pain, and confusion between stimulus and response and between the perspectives of the experiencer and the observer of "pain." Secondly, fallacies in reasoning are identified that contribute to imprecision and confusion. These include reification of pain, attributing to the brain functions that belong to whole organisms, and the illusory truth effect. Thirdly, these themes are identified also in constructs that are shown to be based more on speculation than on fact. Taken together, these observations reveal a need to review and, where necessary, modify terminology and concepts used in Pain Medicine. PERSPECTIVE: This article examines a number of words and constructs commonly found in the pain literature from the perspective of accuracy in terms of their consistency of usage, concordance with fact, degree of speculation and logical argument. A common major theme is the error of considering pain as a "thing" that has agentive properties. A need to clarify much of the language used in Pain Medicine is identified.

Attitudinal responses to current concepts and opinions from pain neuroscience education on social media.

BACKGROUND: Pain neuroscience education (PNE) programs have become popular among clinicians and are widely promoted through social and mainstream media. PURPOSE: To test the hypothesis that people with persistent pain are likely to express negative attitudes to PNE statements and compare their responses to other social media user groups. METHODS: A total of 1319 respondents completed an online survey and were directed into four groups: persistent pain, healthcare professionals with persistent pain, pain-free healthcare professionals, and pain-free controls. The survey included ten statements of popular PNE concepts. Feedback was invited by offering seven attitudinal response categories (three positives, three negatives, and one neutral). A two-step hierarchical regression model was used to assess the likelihood of reporting negatively. RESULTS: Compared to controls, respondents from the persistent pain group were more likely to report negatively towards all statements (OR 1.6-2.16), except for two statements (#3 and #5). Healthcare professionals were less likely to report negative attitudes for 4 out of 10 statement (OR 0.35-0.58). Health care professionals living with persistent responded to most statements like the pain-free controls (besides statement #2, OR 0.59). CONCLUSION: People living with persistent pain are more likely to express negative attitudes to PNE statements on social media, unlike healthcare professionals who were less likely to express negativity. Healthcare professionals living with persistent pain responded to most PNE statements like the pain-free control group. The study's main weaknesses include the lack of psychometric information of the questionnaire used, selection bias, small samples of the healthcare professionals and the overrepresentation of young social media users.

High Levels of Self-Reported Depressive Symptoms Among Physical Therapists and Physical Therapist Students Are Associated With Musculoskeletal Pain: A Cross-Sectional Study.

OBJECTIVE: Depressive symptoms and musculoskeletal (MSK) pain are 2 of the most common health conditions. Their relationship, however, remains unclear. As depressive symptoms in physical therapists have not been well assessed, the purpose of this work was to assess self-reported depressive symptoms and MSK pain prevalence-and their possible association-in physical therapists and physical therapist students. METHODS: An online cross-sectional survey was used to gather data from 707 physical therapists and 116 physical therapist students from Israel. The Patient Health Questionnaire-9 was used to assess depressive symptoms, and the Extended Nordic Musculoskeletal Questionnaire was used to evaluate the prevalence and characteristics of MSK pain. RESULTS: Overall, 108 participants (13.1%) scored in the moderate to severe depressive symptoms category (Patient Health Questionnaire-9 score >10), and 261 participants (31.7%) scored in the mild depressive symptoms category. In total, 84 physical therapists (11.9%) and 24 physical therapist students (20.7%) reported moderate to severe depressive symptoms during the last 2 weeks. Neck and back pain had the highest point prevalence (26.7%-35.3%) and lifetime prevalence (75.9%-78.5%), respectively. Mild depressive symptoms were associated with current pain (adjusted odds ratio [OR] = 1.58) and smoking (adjusted OR = 1.79-1.84). Current pain was also associated with severe depressive symptoms (adjusted OR = 2.76-3.07). Physical therapists with higher salaries were less likely to report severe depressive symptoms (adjusted OR = 0.11-0.36). CONCLUSION: The prevalence estimates generated from this study sample imply that 11.9% of physical therapists and 20.7% of physical therapist students in Israel experienced moderate to severe depressive symptoms. Neck and back pain had the highest point and lifetime prevalence. IMPACT: The prevalence of self-reported depressive symptoms in this sample places physical therapists and physical therapist students alongside physicians, nurses, and medical profession students who have been previously reported to have elevated depressive symptoms. Future studies should further explore the nature of the association between pain and depressive symptoms in these populations.

A morphological characterization of the lumbar neural arch in females and males with degenerative spondylolisthesis.

BACKGROUND: Although Degenerative Spondylolisthesis (DS) is a common osseous dysfunction, very few studies have examined the bony morphology of lumbar the neural arch in the population afflicted with DS. Therefore, this study aimed to characterize the neural arch (NA) morphology along the entire lumbar spine in individuals with degenerative spondylolisthesis (DS) and compare them to healthy controls. METHODS: One hundred CTs from a database of 500 lumbar CTs of spondylolisthesis were selected. We excluded vertebral fractures, non-L4-L5 slips, previous surgeries, vertebral spondyloarthropathies, and scoliosis. Scans were divided into a study group of 50 individuals with single-level DS (grades 1-2) at L4-5 (25 males and 25 females), and an age-sex matched control group of 50 individuals. Linear and angular measurements from all lumbar segments included: vertebral canals, intervertebral foramens, pedicles, and articular facets. RESULTS: Compared with the controls, all individuals with DS had greater pedicle dimensions in the lower lumbar segments (∆ = 1 mm-2.14 mm) and shorter intervertebral foramens in all the lumbar segments (∆range:1.85 mm-3.94 mm). In DS females, the lower lumbar facets were mostly wider (∆ = 1.73-2.86 mm) and more sagittally-oriented (∆10°) than the controls. Greater prevalence of grade-3 facet arthrosis was found only in the DS population (DS = 40-90%,controls = 16.7-66.7%). In DS males, degenerated facets were observed along the entire lumbar spine (L1-S1), whereas, in DS females, the facets were observed mainly in the lower lumbar segments (L4-S1). Individuals with DS have shorter intervertebral foramens and greater pedicle dimensions compared with controls. CONCLUSIONS: Females with DS have wider articular facets, more sagittally-oriented facets, and excessively degenerated facets than the controls. This unique NA shape may further clarify DS's pathophysiology and explain its greater prevalence in females compared to males.

A comparative shape analysis of the cervical spine between individuals with cervicogenic headaches and asymptomatic controls.

As some researchers theorized that cervicogenic headache (CEH) might be related to bony and discal features of the cervical spine, this retrospective study examined the shapes of the cervical vertebrae and intervertebral discs (IVDs) of individuals with CEH and compared them to asymptomatic controls. Scans of 40 subjects in their late 20's-mid 30's affected with CEH and 40 asymptomatic controls were obtained (overall = 19,040 measurements, age-sex matched, 20 males and 20 females in each group). The following cervical spine variables were measured: Supine lordosis, vertebral body-heights, A-P lengths, mediolateral widths and sagittal-wedging; IVDs heights and sagittal-wedging; pedicle heights, widths and transverse angles; laminar widths and transverse angles; articular facet angles, spinal canal, and transverse foramen lengths, widths, and areas. Both groups had similar shape variation along the cervical in all the measured parameters. There were no significant left-right differences in all measured parameters and no significant differences between the CEH and control groups concerning sex and age. Cervical IVDs were lordotic in shape, whereas their adjacent vertebral bodies were kyphotic in shape except for C2. In conclusion, the shape of the cervical spine and IVDs in subjects in their late 20's-mid 30's affected with CEH is identical to asymptomatic controls.

The relationship between diastasis rectus abdominus, pelvic floor trauma and function in primiparous women postpartum.

INTRODUCTION AND HYPOTHESIS: A functional interaction exists between the pelvic floor and the abdominal wall. The study was aimed at investigating the clinical and morphological relationships between diastasis rectus abdominus (DRA) and pelvic floor trauma in primiparous women. METHODS: Eighteen women suffering from DRA and 18 women without DRA (non-DRA group), all primiparous with pelvic floor trauma, were enrolled in the study. Ultrasound was performed on the 36 women examining the inter-rectus distance, pelvic floor morphology, abdominal muscle force (MMT), Static Abdominal Flexion Endurance Test (SFET), and Dynamic Abdominal Flexion Endurance Test (DFET), abdominal circumference, visual analog scale, and responses to the Oswestry Low Back Pain Questionnaire and the Pelvic Floor Distress Inventory questionnaire (PFDI). RESULTS: A significant increase in the urinary symptoms portion of the in PFDI-20 questionnaire was found in the DRA group (non-DRA = 12.5 ± 22.8, DRA = 26.8 ± 18.2, p = 0.01). A significant reduction in abdominal force and endurance was observed in the DRA2-3 group compared with the DRA0-1 group (0.025 < p < 0.04). DFET (average repetitions) in the DRA0-1 group measured 13.4 ± 11.8 and 6.46 ± 4.59 in the DRA2-3 group (p = 0.025). SFET was 20.48 ± 14.46 s in the DRA0-1 group and 10.62 ± 10.6 s in the DRA2-3 group (p = 0.031). MMT was 4 in the DRA0-1 group and 3 in the DRA2-3 group (p = 0.04). CONCLUSIONS: Diastasis rectus abdominus does not correlate with morphological changes in the pelvic floor, but does correlate with higher scores in the urinary symptoms portion of the PFDI-20. Women suffering from DRA do not endure more pain or greater lumbar disability than non-DRA women. In extended DRA, the abdominal muscles are significantly compromised and weaker.

The cross-cultural adaptation and reliability of the online Hebrew version of the extended Nordic Musculoskeletal Questionnaire.

BACKGROUND: The Nordic Musculoskeletal Questionnaire assesses musculoskeletal (NMQ) symptoms in occupational environments. Physiotherapists are known to work with their bodies, and hence prone to occupational musculoskeletal injuries. To date, there is no Hebrew version of the extended version of the NMQ (NMQ-E). PURPOSE: To cross-culturally adapt the NMQ-E into Hebrew and evaluate the intra-rater reliability of the online Hebrew version (HNMQ-E) in a population of physiotherapists. METHODS: After cross-cultural adaptation, test-retest reliability over a week was assessed with 65 participants who had no change in their health status over the past week. Statistical analysis included the calculation of Cohen's kappa coefficient (κ), observed proportions of agreement, and intraclass correlations. RESULTS: Intra-rater reliability for the prevalence of pain was moderate to substantial (κ = 0.51-0.80), and highly variable agreement for questions about pain consequences (κ = 0.20-0.94). Observed proportions of agreement were higher than 0.78 for all the items. The mean completion time of the survey was 6:30 ± 3:37. CONCLUSIONS: The online version of the HNMQ-E has been found to be reliable and practical. Future studies on the properties of the HNMQ-E should investigate more general working populations.

Individuals with back and neck pain on medical forums: What do they mention? What do they fear?

BACKGROUND: The use of online medical forums is on the rise globally. Data scraping is a method of extracting website content using an automated computer program. We scraped users' questions regarding back and neck pain (BNP) from popular Israeli online medical forums. We aimed to identify the sort of questions being asked about BNP, and to analyse explicit themes that characterize their questions. METHODS: Six leading Israeli BNP forums were identified. In phase 1, Python scripts scraped 12,418 questions into a data set. In phase 2 - five themes were identified: Surgery (n = 2,957); health care professions (n = 2,361); Sports (n = 2,304); drugs (n = 1,419) and interpretation of imaging (n = 845). Phase 3 - included the categorization of explicit fear-related words by the authors. Phase 4 - analysis of explicit fear-related themes yielded 402 questions. RESULTS: Gender was identified for 394 users, and age was identified for 181 users. A total of 248 users (61.6%) were women and 146 men (36.3%). Mean age 36.3 ± 16.15 for women and 35.5 ± 16.1 for men. The most commonly expressed fears were related to: invasive procedures, 30.9% (131 questions); fear of serious condition or misdiagnosis, 17.0% (72 questions); General concerns, 13.7% (58 questions); fear of worsening or relapse, 12.3% (52 questions); adverse effects of oral drugs or radiation, 10.8% (46 questions) and concerns related to lifestyle, 9.7% (41 questions). CONCLUSIONS: Web scraping is a feasible strategy with which to explore medical forums and the above-mentioned themes, all of which are of potential clinical significance. SIGNIFICANCE: Using automated algorithms, a total of 12,369 questions from online back and neck medical forums were scraped and analysed. Secondary analysis categorized fear-related themes that were mentioned by users. Identifying and addressing patients' fear has potential to improve communication and therapeutic outcome. For example, questions regarding surgery were typically asked after the option was mentioned by a physician. This insight should encourage physicians to devote extra time explaining the possible implications of surgery, should they consider it as an option.

Why are assumptions passed off as established knowledge?

In this paper we attempt to explain the problems that can arise when assumptions made by experts in their respective fields of Medicine become widely accepted as established knowledge. Our hypothesis is that these problems are in large part attributable to a failure of the experts to follow the principles of logical argument. Empirical data to evaluate our hypothesis derives from an analysis of the reasoning processes employed in the generation of three syndromes drawn from the clinical discipline of Pain Medicine: myofascial pain, shoulder impingement and central sensitisation. We demonstrate a failure by the proponents of these syndromes to structure their scientific arguments in a logically valid fashion, which lead them to promote assumptions to the status of facts. In each instance those in relevant scientific journals responsible for content review accepted - and thereby promulgated - this fundamental error in reasoning. The wide acceptance of each of these assumptions as established knowledge affirms our hypothesis. Furthermore, we show that such uncritical acceptance has had significant consequences for many patients.