Barriers to Physiotherapists' Use of Professional Development Tools for Chronic Pain: A Knowledge Translation Study.

Purpose: The Pain Science Division (PSD) is a special interest group of the Canadian Physiotherapy Association that serves physiotherapists who have an interest in better understanding and managing patients' pain. The PSD developed evidence-based resources for its members with the goal of improving patient care by supporting professional development. However, online metrics tracking access to these resources indicated that access was low. The purpose of this study was to identify the barriers PSD members encountered to the use of PSD resources and to recommend interventions to address these barriers guided by the Theory and Techniques Tool (TTT). Method: We distributed an online survey to PSD members across Canada. We used the TTT, a knowledge translation tool, to guide the design of the questionnaire and identify actionable findings. Results: Response rates from 621 non-student members and 1,470 student members were 26.9% and 1.4%, respectively. Based on the frequency of practising physiotherapists' (n = 167) agreement with items in the TTT, the primary barriers to use of the PSD resources were forgetting that the resources were available and forgetting to use them. Conclusions: The TTT can be used to identify barriers to use of professional development tools.

Objectif : la division science de la douleur (DSD) est un groupe d'intérêt de l'Association canadienne de physiothérapie destiné aux physiothérapeutes qui souhaitent mieux comprendre et gérer la douleur des patients. La DSD a préparé des ressources fondées sur des données probantes pour ses membres afin d'améliorer les soins aux patients grâce au perfectionnement professionnel. Cependant, les mesures virtuelles qui surveillent l'accès à ces ressources ont révélé que cet accès était limité. La présente étude visait à établir les obstacles auxquels se sont heurtés les membres de la DSD pour utiliser les ressources de la DSD et à recommander des interventions afin d'écarter ces obstacles en fonction de l'outil Theory and Techniques (TTT). Méthodologie : les chercheurs ont distribué un sondage en ligne aux membres de la DSD du Canada. Ils ont utilisé le TTT, un outil d'application des connaissances, pour orienter la conception du questionnaire et déterminer les résultats réalisables. Résultats : le taux de réponse des 621 membres non étudiants et des 1 470 membres étudiants s'établissait à 26,9 % et à 1,4 %, respectivement. D'après la fréquence d'accord des physiothérapeutes en exercice (n = 167) avec les points du TTT, l'oubli de l'existence des ressources ou l'oubli de les utiliser étaient les principaux obstacles à l'utilisation des ressources de la DSD. Conclusions : le TTT peut être utilisé pour déterminer les obstacles à l'utilisation d'outils de perfectionnement professionnel.

The Prospective Prognostic Value of Biopsychosocial Indices of Sensitivity to Physical Activity Among People With Back Pain.

OBJECTIVES: Many people living with musculoskeletal pain conditions experience a range of negative biopsychosocial responses to physical activity, referred to as increased sensitivity to physical activity (SPA), that may undermine successful rehabilitation. This exploratory study aims to provide the first prospective analysis of the potential prognostic value of 3 biopsychosocial indices of SPA in relation to rehabilitation outcomes. This study also aimed to shed light on the cross-sectional interrelationships between these 3 biopsychosocial indices of SPA. MATERIALS AND METHODS: Adults with back pain were evaluated upon starting physical therapy and then again 3 months later. The initial testing session consisted of self-reported pain-related questionnaires and assessment of activity-related changes in pressure pain thresholds (SPA-Sensory), pain intensity ratings (SPA-Pain), and situational catastrophizing (SPA-Psych). The 3-month follow-up consisted of self-reported disability and pain questionnaires. Correlational and hierarchical linear regression analyses were conducted. RESULTS: A total of 97 participants completed both the initial visit and 3-month follow-up. The SPA-Pain index and the SPA-Psych index were significantly intercorrelated, but neither were correlated with the SPA-Sensory index. The SPA-Sensory index was not correlated with outcomes. The SPA-Pain index was correlated only with cross-sectional disability and pain outcomes. The SPA-Psych index was the only SPA index significantly correlated with outcomes both cross-sectionally and at 3-month follow-up. After controlling for baseline pain/disability and pain catastrophizing, SPA-Psych was no longer a significant prognostic factor for pain, but remained a significant prognostic factor for disability at 3-month follow-up (ß=0.272, t=2.674, P=0.008, R2 Δ=5.60%). DISCUSSION: This study highlights the importance of conceptualizing and measuring SPA as a biopsychosocial (rather than unidimensional) construct and points toward the added prognostic value of this construct. Implications for future research and practice are discussed.

A Cumulative Impact of Psychological and Sensitization Risk Factors on Pain-Related Outcomes.

OBJECTIVE: Risk constructs based on psychological risk factors (eg, pain catastrophizing, PC) and sensitization risk factors (eg, pressure pain threshold, PPT) are important in research and clinical practice. Most research looks at individual constructs but does not consider how different constructs might interact within the same individual. An evaluation of the cumulative impact of psychological and sensitization risk factors on pain-related outcomes may help guide us in the risk assessment of patients with pain conditions. The aim of this study is to evaluate the cumulative impact of these psychological (PC) and sensitization (PPT) risk factors on pain-related outcomes (activity avoidance, pain severity, and disability) considering covariates. METHODS: We included 109 participants (70.60% women; mean ± SD age 53.6 ± 12.3 years) with chronic musculoskeletal pain for data analysis, who completed all measures of this study. Participants completed a single testing session that included measures of risk factors (PC and PPT) and pain-related outcomes (self-reported avoidance, functional avoidance, disability, and pain severity). Subgroups were constructed by dichotomizing of PC and PPT scores, resulting in four groups: (1) low catastrophizing and low sensitivity (N = 26), (2) high catastrophizing and low sensitivity (N = 27), (3) low catastrophizing and high sensitivity (N = 25), and (4) high catastrophizing and high sensitivity (N = 31). RESULTS: One-way analysis of variance (ANOVA) revealed significant group differences (P < 0.05, η2  = 0.08 to 0.14) in all outcomes of this study (except functional avoidance), and post hoc analysis indicated the significant differences are between group 1 and 4. A cumulative impact is reflected by large effect sizes between group 1 and 4 (d = 0.8 to 1). The group 2 and 3 (one risk dimension groups: either high-PC or high-PPT) represent 47% of the total participants. CONCLUSIONS: The study suggests both higher level of PC and pressure sensitivity have a cumulative impact on risk screening for pain-related outcomes, considering gender in functional avoidance (task-related outcome). A clinical presentation with high-PC (one dimension of risk) is not associated with high-PPT (another dimension of risk). This finding has important clinical and theoretical implications.

Comparing Novel and Existing Measures of Sensitivity to Physical Activity Among People With Chronic Musculoskeletal Pain: The Importance of Tailoring Activity to Pain.

OBJECTIVES: Increasing pain during physical activity is an important, but often poorly assessed, barrier to engaging in activity-based rehabilitation among people with chronic musculoskeletal pain. Preliminary work has addressed this problem by developing new clinical measures of sensitivity to physical activity (SPA). Indices of SPA are generated by evaluating how pain changes in relation to brief physical tasks. Three strategies have been identified for structuring SPA-related physical tasks (self-paced, standardized, and tailored). This cross-sectional study aimed to comparatively estimate the extent of the 3 SPA tasks' evoked pain responses, predictive value of pain severity and pain interference, and their underlying psychological and sensory constructs, among 116 adults with chronic musculoskeletal pain. MATERIALS AND METHODS: Testing included questionnaires, quantitative sensory testing, and the 3 SPA measures (self-paced, standardized, and tailored). The primary analysis estimated the predictive value of each SPA measure for pain severity and pain interference. Correlational analyses were first conducted between all variables of interest to determine what variables will be included in the hierarchical regression analysis, which in turn was conducted for each outcome. RESULTS: Analyses revealed that the tailored SPA index was most effective at evoking activity-related pain, was uniquely associated with temporal summation of pain, and was a unique predictor of pain and pain-related interference, even when controlling for established psychological and sensory risk factors. DISCUSSION: This study further emphasizes SPA as an important and unique attribute of the pain experience and reveals the added value of using a tailored approach to assess SPA.

From Paper to Digitalized Body Map: A Reliability Study of the Pain Area.

BACKGROUND: Computerized methods to analyze pain drawings (PDs) have been developed and may aid to measure the pain area more precisely. OBJECTIVE: The aim of this study was to verify whether examiners can reproduce the patient's PDs with acceptable reliability. METHODS: This was an intra-rater and inter-rater reliability study. The protocol consisted of 4 steps: (1) scanning of paper PDs; (2) sharing the digitalized PD images between examiners; (3) reproducing the PD images in the sketching application; and (4) calculating the pain area in pixels and percentages. We calculated intraclass correlation coefficients (ICCs; 2,1), the standard error of the measurement (SEM), and the smallest detectable difference (SDD). RESULTS: Reliability was tested using 31 PDs from 17 patients in our database (11 female [64.7%], mean age: 53.23 ± 11.57 years). Intra-rater reliability varied from ICC (2,1) = 0.991 (95% confidence interval [CI] = 0.982 to 0.996; SEM = 3,432.45; SDD = 162.39 pixels; P < 0.001) to ICC (2,1) = 0.992 (95% CI = 0.978 to 0.997; SEM = 3,412.96; SDD = 161.93 pixels; P < 0.001). Inter-rater reliability for the measurement between all examiners was considered excellent (ICC [2,1] = 0.976; 95% CI = 0.956 to 0.987; SEM =8,580.75; SDD = 256.76 pixels; P < 0.001), being higher between Examiners A and C (ICC [2,1] = 0.970; 95% CI = 0.936 to 0.986; SEM = 6,453.34; SDD = 222.67 pixels; P < 0.001). CONCLUSION: Our results show that intra- and inter-rater reliabilities were excellent when an examiner reproduced the paper PDs into digitalized PDs. This process gives clinicians and researchers the opportunity to analyze pain extent more precisely using a computerized method.

Evaluating the novel added value of neurophysiological pain sensitivity within the fear-avoidance model of pain.

BACKGROUND: The fear-avoidance model (FAM) is a leading theoretical paradigm for explaining persistent pain following musculoskeletal injury. The model suggests that as injuries heal, pain-related outcomes are increasingly determined by psychological, rather than physiological factors. Increasing literature, however, suggests that neurophysiological processes related to pain sensitivity also play an important role in chronicity. To date, there has been limited research that has specifically explored the role of pain sensitivity within the FAM. This study addresses this gap by evaluating whether clinical measures of pain sensitivity help explain FAM-related outcomes, beyond model-relevant psychological predictors. METHODS: The study sample consisted of 80 adults with chronic and widespread musculoskeletal pain. Participants completed a single testing session that included measures of all of the major constructs of the FAM, including pain catastrophizing, pain-related fear, activity avoidance (self-report and functional measures), pain-related disability, depression and pain severity, as well as a battery of quantitative sensory testing that included measures of pressure pain threshold and temporal summation of mechanical pain across eight body sites. RESULTS: A series of hierarchical regression analyses revealed that after controlling for the psychological predictors of the FAM, indices of pain sensitivity significantly predicted 4 of the 5 FAM-related outcomes (p < 0.05). Depression was the only outcome not significantly predicted by pain sensitivity. Interestingly, measures of pain sensitivity, but not FAM psychological factors, predicted the functional measure of activity avoidance. CONCLUSIONS: These findings provide further evidence for the importance of neurophysiological factors within the FAM and have important clinical and theoretical implications. SIGNIFICANCE: This study provides evidence for the unique and added value of neurophysiological factors within the Fear Avoidance Model of pain and for the importance of integrating both sensory and psychological factors within both theoretical paradigms and clinical management strategies.

Factors Affecting Length of Stay in Adult Outpatient Physical Rehabilitation: A Scoping Review of the Literature.

PURPOSE: To identify factors affecting length of stay (LOS) for adults participating in outpatient physical or occupational therapy programmes. METHOD: A scoping review of the literature was conducted using the Ovid MEDLINE, EMBASE, CINAHL, AMED, and Cochrane Library databases. RESULTS: A total of 19 articles were retained from the search, and 2 additional articles were retrieved from grey literature (i.e., non-published sources). Personal factors affecting LOS are age and sex, both of which had inconsistent effects on LOS, and communication, language, physical, and cognitive difficulties, for which higher levels of function were generally associated with shorter LOS. Institutional factors affecting LOS were location, interdisciplinary communication, number of disciplines involved, and type of rehabilitation setting. Finally, two clinician-related factors-fewer treatment goals and a selection of evidence-informed treatment techniques-were associated with shorter LOS. CONCLUSIONS: Research on factors affecting adult outpatient rehabilitation LOS is limited and inconsistent. A preliminary list of LOS factors was produced, but this topic should be further explored with the collaboration of researchers and clinical institutions.

Objet: Déterminer les facteurs qui ont un effet sur la durée du séjour (DDS) chez les adultes participant à des programmes de physiothérapie ou d'ergothérapie en service externe. Méthode: On a effectué une recherche documentaire dans les bases de données Ovid MEDLINE, EMBASE, CINAHL, AMED et Cochrane. Résultats: Au total, la recherche a produit 19 articles qui ont été retenus et deux autres ont été extraits de la littérature grise (c.-à-d. de sources non publiées). Les facteurs personnels qui ont un effet sur la DDS sont l'âge et le sexe, qui avaient tous deux des effets non uniformes sur la DDS, ainsi que la communication, la langue, les problèmes physiques et cognitifs dans le cas desquels on établissait en général un lien entre des niveaux plus élevés de fonctionnement et une DDS plus courte. Les facteurs institutionnels qui ont un effet sur la DDS sont le lieu, la communication interdisciplinaire, le nombre de disciplines en cause et le type de contexte de réadaptation. Enfin, on a établi un lien entre deux facteurs liés aux cliniciens­objectifs de traitement moins nombreux et sélection de techniques de traitement éclairées par des données probantes­et une DDS plus courte. Conclusions: La recherche sur les facteurs qui ont un effet sur la DDS en réadaptation en service externe chez les adultes est limitée et incohérente. On a produit une liste préliminaire de facteurs de la DDS, mais il faudrait explorer la question plus à fond avec la collaboration de chercheurs et d'établissements cliniques.

The effect of previous loading cycles on the reliability of a clinical measure of hamstring flexibility.

PURPOSE: The aim of the study was to determine the effect of successive repetitions of a measure of hamstring flexibility-the passive unilateral straight leg raise (SLR)-on the reliability of this measure. METHOD: Ten repetitions of the SLR were performed on nine healthy adults. Measures were quantified using an electromagnetic tracking system and standardized using a handheld dynamometer by stopping the SLR at a set end-point force. The 10 repetitions were analyzed as two blocks of five, and intra-class correlation coefficients-models (2,1) and (3,k)-were calculated for each block of data. RESULTS: ICC values for both models were comparable between the two blocks of data. CONCLUSION: Previous loading cycles, to a set end-point force, are unlikely to improve the reliability of muscle flexibility assessment in a clinical setting.

Objectif : L'objectif de cette étude était de déterminer l'effet de répétitions successives d'une mesure de la souplesse de l'ischio-jambier ­ l'élévation passive unilatérale de la jambe tendue (SLR) ­ sur la fiabilité de cette mesure. Méthode : Dix répétitions d'élévations passives unilatérales de la jambe tendue ont été réalisées chez neuf adultes en bonne santé. Les mesures ont été quantifiées à l'aide d'un système de suivi électromagnétique, puis normalisées à l'aide d'un dynamomètre manuel à un point prédéterminé de l'extrémité finale du mouvement. Les 10 répétitions ont été analysées en deux groupes de cinq, et des coefficients de corrélation intraclasses ­ modèles (2,1) et (3,k) ­ ont été calculés pour chaque groupe de données. Résultats : La valeur du CCI pour les deux modèles ont été comparables entre les deux blocs de données. Conclusion : Il est peu probable que les cycles de charge antérieurs préétablis à l'extrémité finale du mouvement améliorent la fiabilité de l'évaluation de la souplesse musculaire dans un cadre clinique.