Evaluation of treatment parameters for focused-extracorporeal shock wave therapy in knee osteoarthritis patients with bone marrow lesions: a pilot study.

OBJECTIVES: To evaluate the effect of different dosage parameters of focused-extracorporeal shock wave therapy on pain and physical function in knee osteoarthritis patients with bone marrow lesions. In addition, to investigate pathophysiological changes based on imaging and biomarker measures. METHODS: Using a single-case experimental design, a total of 12 participants were randomly allocated in 4 equal groups of 3 to receive different dosages of focused-extracorporeal shock wave therapy. Each group received either 4 or 6 sessions of 1500 or 3000 shocks over 4 or 6 weekly sessions. Participants underwent repeated measurements during the baseline, intervention, and post-intervention phases for Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, aggregated locomotor function score and pressure pain threshold. Imaging and inflammatory biomarker outcomes were measured at baseline and 3 months following the intervention. RESULTS: The group receiving the highest dosage of focused-extracorporeal shock wave therapy showed clinical improvements superior to those of participants in the other 3 groups. Statistically significant changes during the follow-up phase in contrast to baseline measurements for the WOMAC score (Tau-U= -0.88, p < 0.001), aggregated locomotor function score (Tau-U= -0.77, p = 0.002), and pressure pain threshold (Tau-U= 0.54, p = 0.03) were observed. Bone marrow lesion and inflammatory cytokines demonstrated no change. CONCLUSION: A dose-dependent effect for focused-extracorporeal shock wave therapy on osteoarthritis-related symptoms was suggested. However, these improvements were not associated with changes in the underlying pathophysiological mechanisms.

Simulation-based clinical assessment identifies threshold competence to practise physiotherapy in Australia: a crossover trial.

BACKGROUND: Although evidence exists for the efficacy of high-fidelity simulation as an educational tool, there is limited evidence for its application in high-stakes professional threshold competency assessment. An alternative model of simulation-based assessment was developed by the Australian Physiotherapy Council (APC), using purpose-written standardised patients, mapped to the appropriate threshold level. The aim of this two-phase study was to investigate whether simulation-based clinical assessments resulted in equivalent outcomes to standard, real-life assessments for overseas-trained physiotherapists seeking registration to practice in Australia. METHODS: A randomised crossover trial comparing simulation-based assessment to real-life assessment was completed. Participants were internationally trained physiotherapists applying for registration to practice in Australia, voluntarily recruited from the Australian Physiotherapy Council (APC) assessment waiting list: study 1 n = 25, study 2 n = 144. Study 1 participants completed usual APC real-life assessments in 3 practice areas, completed on different days at APC partner healthcare facilities. Participants also underwent 3 practice area-matched simulation-based assessments, completed on the same day at purpose-designed simulation facilities. Study 2 participants completed 3 simulation-based assessments and 1 real-life assessment that was randomly allocated for order and practice area. Assessment of competency followed the standard APC procedure of 90-minute examinations using The Moderated Assessment Form (MAF). RESULTS: The overall pass rate was higher for real-life assessments in both studies: study 1, 50% versus 42.7%; study 2, 55.6% versus 44.4%. Chi-square analysis showed a high to moderate level of exact matching of pass/fail grades across all assessments: study 1, 73.4% (p < 0.001); study 2, 58.3% (p = 0.027). Binary logistic regression showed that the best predictors of real-life pass/fail grade were simulation-based MAF pass/fail grade (study 1, OR 7.86 p < 0.001; study 2, OR 2.037, p = 0.038) and simulation-based total MAF score (study 1, OR 1.464 p < 0.001; study 2, OR 1.234, p = 0.001). CONCLUSION: Simulation-based assessment is a significant predictor of clinical performance and can be used to successfully identify high stakes threshold competence to practice physiotherapy in Australia.

The Influence of a Positive Empathetic Interaction on Conditioned Pain Modulation and Manipulation-induced Analgesia in People With Lateral Epicondylalgia.

OBJECTIVE: Conditioned pain modulation (CPM) and manipulation-induced analgesia (MIA) are 2 forms of endogenous analgesia. Many forms of analgesia can be influenced by the nature of the patient-clinician interaction. The aim of this study was to evaluate the influence of an empathetic and supportive interaction on CPM and MIA in people with lateral epicondylalgia (LE). MATERIAL AND METHODS: In a double-blind, randomized, controlled trial, 68 participants with LE were assigned to 2 groups: the empathetic and neutral interaction groups. The interactions were carried out by a trained, professional role-play actor, playing the part of a research assistant. The research assistant actor spent 15 minutes before CPM and MIA assessment interacting with the participants in an empathetic or neutral manner. Immediately after the interaction, a blinded assessor measured pressure pain threshold at the symptomatic elbow and ipsilateral wrist during CPM and MIA testing. Linear mixed models were used to evaluate differences in CPM and MIA responses between the interaction groups. RESULTS: There was a significant difference in Consultation and Relational Empathy scores between the groups (P<0.001), indicating that the intervention group experienced a more empathic interaction. Both groups showed a significant increase in pressure pain threshold measures, indicative of a CPM and MIA analgesic response (P<0.001), however, the analgesic responses were greater in the group that had experienced a supportive, empathetic interaction (post CPM, wrist: P<0.001; elbow: P=0.001) (post MIA wrist: P<0.001; elbow: P=0.001). DISCUSSION: A single session of empathetic interaction positively influenced both CPM and MIA responses in people with LE.

Monitoring the Clinical Response to an Innovative Transdermal Delivery System for Ibuprofen.

We present a phase 1 study that utilizes a crossover design that provides a rapid and relatively inexpensive methodology for evaluating a new transdermal product. The treatment for osteoarthritis (OA) aims to reduce pain and improve function. An innovative magnetophoresis technology has been developed that facilitates transdermal delivery of ibuprofen. The study used measures that were taken over a relatively short time period to monitor the pharmacodynamic response to ibuprofen. Each participant received magnetophoresis-enhanced transdermal ibuprofen or placebo in randomised order, with a five-day washout period. The participants were 24 volunteers with medically diagnosed, painful knee OA. The primary outcome measures were VAS rating of pain on movement and Western Ontario and McMaster Universities (WOMAC) pain and function scores. VAS for pain on movement (p < 0.001), WOMAC pain score (p = 0.004), and WOMAC function score (p = 0.004) were all significantly improved. There was a significant reduction in movement-related pain (p < 0.05) during the first patch application and for the remainder of the study period. The number needed to treat for a 50% reduction in movement related pain was 2.2. The study showed a rapid and significant analgesic effect in response to transdermal ibuprofen. A short trial of this nature can be used for informing the parameters that are required for a major randomised controlled trial.

Development of a topical menthol stimulus to evaluate cold hyperalgesia.

PURPOSE: Cold hyperalgesia is an indicator of widespread pain sensitivity and is associated with poor clinical outcomes. Menthol activates TRPM8, a cold-sensing receptor channel. This research evaluated topical menthol as a potential stimulus to be used in the clinical evaluation of cold hyperalgesia. METHODS: Participants were 59 pain free volunteers (17 male: 42 female). A blinded, repeated measures design was used. Participants received applications of menthol at different concentrations in a liquid (study 1) or gel (study 2) formulation with a 24-h interval between each application. Each menthol concentration was applied for 15 min and participants were asked to rate the sensation produced using a series of visual analogue scales and by selecting words from a descriptor list derived from the McGill pain questionnaire (MPQ). The menthol was applied to a site on the volar forearm. Participants also had their cold pain thresholds (CPT) evaluated at the same site using a contact thermode. RESULTS: There were significant concentration-dependent effects for intensity of cold, unpleasantness and pain VAS: cold F(2,62) = 8.67, p < 0.001; unpleasantness χ2(2) = 14.14, p < 0.001; χ2(2) = 11.74, p = 0.003, with moderate effect sizes for unpleasantness and pain. There were also significant concentration dependent effects for descriptor indices, pain rating index (PRI) F(2,62) = 26.33, p < 0.001; number of words chosen (NWC) F(2,62) = 19.62, p < 0.001, with large effect sizes for 10-20% and 10-30% comparisons. Significant correlations were seen between measures of unpleasantness, pain, PRI, NWC and CPT dependent on menthol concentration. CONCLUSION: Topical menthol has potential as a stimulus to evaluate cold hyperalgesia.

The Association Between Conditioned Pain Modulation and Manipulation-induced Analgesia in People With Lateral Epicondylalgia.

OBJECTIVES: Conditioned pain modulation (CPM) and manipulation-induced analgesia (MIA) may activate similar neurophysiological mechanisms to mediate their analgesic effects. This study assessed the association between CPM and MIA responses in people with lateral epicondylalgia. MATERIALS AND METHODS: Seventy participants with lateral epicondylalgia were assessed for CPM followed by MIA. A single assessor measured pressure pain thresholds (PPT) before, during, and after cold water immersion (10°C) of the asymptomatic hand and contralateral lateral glide (CLG) mobilization of the neck. For analyses, linear mixed models evaluated differences in CPM and MIA responses. Pearson partial correlations and regression analyses evaluated the association between CPM and MIA PPT. RESULTS: There was a significant increase (CPM and MIA, P<0.001) in PPT from baseline during the interventions (CPM mean: 195.84 kPa for elbow and 201.87 kPa for wrist, MIA mean: 123.01 kPa for elbow and 126.06 kPa for wrist) and after the interventions (CPM mean: 126.06 kPa for elbow, 114.24 kPa for wrist, MIA mean: 123.50 kPa for elbow and 122.16 kPa for wrist). There were also significant moderate and positive partial linear correlations (r: 0.40 to 0.54, P<0.001) between CPM and MIA measures, controlling for baseline measures. Regression analyses showed that CPM PPT was a significant predictor of MIA PPT (P<0.001) and the models explained between 73% and 85% of the variance in MIA PPT. DISCUSSION: This study showed that CPM and MIA responses were significantly correlated and that the CPM response was a significant predictor of MIA response.

Exercise-induced hypoalgesia in women with varying levels of menstrual pain.

BACKGROUND AND AIMS: Exercise-induced hypoalgesia (EIH) is a well-established phenomenon in pain-free individuals that describes a decrease in pain sensitivity after an acute bout of exercise. The EIH response has been demonstrated to be sub-optimal in the presence of persisting pain. Menstrual pain is a common recurrent painful problem with many women experiencing high levels of pain each cycle. However, the EIH response has not been examined in a cohort of women with high levels of menstrual pain. This research aimed to examine whether EIH manifests differently in women with varying levels of menstrual pain. The primary hypothesis was that women with high levels of menstrual pain would demonstrate compromised EIH. Secondary aims were to explore relationships between EIH and emotional state, sleep quality, body mass index (BMI) or physical activity levels. METHODS: Pressure pain thresholds (PPT) were measured in 64 participants using a digital handheld algometer before and after a submaximal isometric-handgrip exercise. EIH index was compared between low (VAS 0-3), moderate (VAS 4-7) and high (VAS 8-10) pain groups, using a linear mixed model analysis with participant as a random effect, and site, menstrual pain category and the interaction between the two, as fixed effects. RESULTS: EIH was consistently induced in all groups. However, there was no statistically significant difference between the pain groups for EIH index (p=0.835) or for any co-variates (p>0.05). CONCLUSIONS: EIH was not found to differ between women who report regular low, moderate or high levels of menstrual pain, when measured at a point in their menstrual cycle when they are pain free. IMPLICATIONS: This study provides insight that EIH does not vary in women with differing levels of menstrual pain when they are not currently experiencing pain. The current findings indicate that, although menstrual pain can involve regular episodes of high pain levels, it may not be associated with the same central nervous system dysfunctions as seen in sustained chronic pain conditions.

The influence of a full-time, immersive simulation-based clinical placement on physiotherapy student confidence during the transition to clinical practice.

BACKGROUND: Novice students may have limited learning opportunities during their early exposure to complex clinical environments, due to the priorities of patient care. Immersive, high-fidelity simulation provides an opportunity for physiotherapy students to be exposed to relatively complex scenarios in a safe learning environment before transitioning to the clinical setting. The present study evaluated the influence of immersive simulation on student confidence and competence. METHODS: Sixty penultimate year physiotherapy students completed an 18-day full-time immersive simulation placement. The placement involved students spending 6 days working in each of three core practice areas (cardiopulmonary, musculoskeletal, neurological) in which they interacted with simulated patients portrayed by professional role-play actors. The patient scenarios were developed by groups of expert practitioners and incorporated full documentary and imaging information. Students completed a questionnaire to evaluate their confidence in the clinical environment at the start and completion of each 6-day rotation. Their clinical competence was evaluated at the end of each 6-day rotation using the Assessment of Physiotherapy Practice (APP) tool. In a secondary analysis, the clinical competence of this cohort was evaluated in comparison to a matched cohort of students from the same year group that had not completed an immersive simulation placement. RESULTS: Student confidence improved significantly in each 6-day rotation (p < 0.001); however, it reduced again at the commencement of the next rotation, and there was no cumulative improvement in confidence over the 18-day placement (p = 0.22). Students who had completed the immersive simulation placement achieved higher APP (p < 0.001) scores in an evaluation of their competence to practice during their subsequent clinical placement. CONCLUSION: Immersive simulation provides a beneficial learning environment to enable physiotherapy students to transition from university-based education to working in the clinical environment.

Endogenous Pain Modulation Induced by Extrinsic and Intrinsic Psychological Threat in Healthy Individuals.

Many factors interact to influence threat perception and the subsequent experience of pain. This study investigated the effect of observing pain (extrinsic threat) and intrinsic threat of pain to oneself on pressure pain threshold (PPT). Forty socially connected pairs of healthy volunteers were threat-primed and randomly allocated to experimental or control roles. An experimental pain modulation paradigm was applied, with non-nociceptive threat cues used as conditioning stimuli. In substudy 1, the extrinsic threat to the experimental participant was observation of the control partner in pain. The control participant underwent hand immersion in noxious and non-noxious water baths in randomized order. Change in the observing participant's PPT from baseline to mid- and postimmersion was calculated. A significant interaction was found for PPT between conditions and test time (F2,78 = 24.9, P < .005). PPT increased by 23.6% ± 19.3% between baseline and during hand immersion (F1,39 = 43.7, P < .005). Substudy 2 investigated threat of imminent pain to self. After a 15-minute break, the experimental participant's PPT was retested ("baseline 2"). Threat was primed by suggestion of whole arm immersion in an icier, larger water bath. PPT was tested immediately before anticipated arm immersion, after which the experiment ended. A significant increase in PPT between "baseline 2" and "pre-immersion" was seen (t = -7.6, P = .005), a pain modulatory effect of 25.8 ± 20.7%. Extrinsic and intrinsic threat of pain, in the absence of any afferent input therefore influences pain modulation. This may need to be considered in studies that use noxious afferent input with populations who show dysfunctional pain modulation. PERSPECTIVE: The effect on endogenous analgesia of observing another's pain and of threat of pain to oneself was investigated. Extrinsic as well as intrinsic threat cues, in the absence of any afferent input, increased pain thresholds, suggesting that mere threat of pain may initiate analgesic effects in traditional noxious experimental paradigms.

Patients With Knee Osteoarthritis Who Score Highly on the PainDETECT Questionnaire Present With Multimodality Hyperalgesia, Increased Pain, and Impaired Physical Function.

OBJECTIVES: PainDETECT is a self-report questionnaire that can be used to identify features of neuropathic pain. A proportion of patients with knee osteoarthritis (OA) score highly on the PainDETECT questionnaire. This study aimed to determine whether those with a higher "positive neuropathic" score on the PainDETECT questionnaire also had greater pain, hypersensitivity, and reduced function compared with individuals with knee OA with lower PainDETECT scores. MATERIALS AND METHODS: In total, 130 participants with knee OA completed the PainDETECT, Western Ontario and McMaster Universities Arthritis Index (WOMAC), and Pain Quality Assessment Scale questionnaires. Quantitative sensory testing was carried out at 3 sites (both knees and elbow) using standard methods. Cold and heat pain thresholds were tested using a Peltier thermode and pressure pain thresholds using a digital algometer. Physical function was assessed using 3 timed locomotor function tests. RESULTS: In total, 22.3% of participants scored in the "positive neuropathic" category with a further 35.4% in the unclear category. Participants in the "positive neuropathic" category reported higher levels of pain and more impaired function based on the WOMAC questionnaire (P<0.0001). They also exhibited increased levels of hyperalgesia at the knee and upper limb sites for all stimulation modalities except heat pain thresholds at the OA knee. They were also slower to complete 2 of the locomotion tasks. DISCUSSION: This study identified a specific subgroup of people with knee OA who exhibited PainDETECT scores in the "positive neuropathic" category. These individuals experienced increased levels of pain, widespread, multimodality hyperalgesia, and greater functional impairment than the remaining cohort. Identification of OA patients with this pain phenotype may permit more targeted and effective pain management.

Cold Pain Threshold Identifies a Subgroup of Individuals With Knee Osteoarthritis That Present With Multimodality Hyperalgesia and Elevated Pain Levels.

OBJECTIVES: Cold hyperalgesia has been established as an important marker of pain severity in a number of conditions. This study aimed to establish the extent to which patients with knee osteoarthritis (OA) demonstrate widespread cold, heat, and pressure hyperalgesia. OA participants with widespread cold hyperalgesia were compared with the remaining OA cohort to determine whether they could be distinguished in terms of hyperalgesia, pain report, pain quality, and physical function. METHODS: A total of 80 participants with knee OA and 40 matched healthy, pain-free controls participated. OA participants completed a washout of their usual medication. Quantitative sensory testing was completed at 3 sites using standard methods. Cold pain threshold (CPT) and heat pain thresholds (HPT) were tested using a Peltier thermode and pressure pain thresholds (PPT) using a digital algometer. All participants completed the short-form health survey questionnaire and OA participants completed the PainDETECT, Western Ontario and McMaster Universities Osteoarthritis Index of the Knee (WOMAC), and pain quality assessment scale questionnaires. RESULTS: OA participants demonstrated widespread cold hyperalgesia (P<0.0001), had lower PPT at the index knee (P<0.0001) compared with controls and reported decreased physical health on the SF-36 (P=0.01). The OA subcohort with high global CPT (≥12.25°C) exhibited multimodality sensitization compared with the remaining OA cohort (PPT P<0.0001; CPT P<0.0001; HPT P=0.021 index knee). This group also reported increased pain, decreased function, and more features of neuropathic pain. DISCUSSION: This study identified a specific subgroup of patients with knee OA who exhibited widespread, multimodality hyperalgesia, more pain, more features of neuropathic pain, and greater functional impairment. Identification of patients with this pain phenotype may permit more targeted and effective pain management.

Quantitative and Qualitative Responses to Topical Cold in Healthy Caucasians Show Variance between Individuals but High Test-Retest Reliability.

Increased sensitivity to cold may be a predictor of persistent pain, but cold pain threshold is often viewed as unreliable. This study aimed to determine the within-subject reliability and between-subject variance of cold response, measured comprehensively as cold pain threshold plus pain intensity and sensation quality at threshold. A test-retest design was used over three sessions, one day apart. Response to cold was assessed at four sites (thenar eminence, volar forearm, tibialis anterior, plantar foot). Cold pain threshold was measured using a Medoc thermode and standard method of limits. Intensity of pain at threshold was rated using a 10cm visual analogue scale. Quality of sensation at threshold was quantified with indices calculated from subjects' selection of descriptors from a standard McGill Pain Questionnaire. Within-subject reliability for each measure was calculated with intra-class correlation coefficients and between-subject variance was evaluated as group coefficient of variation percentage (CV%). Gender and site comparisons were also made. Forty-five healthy adults participated: 20 male, 25 female; mean age 29 (range 18-56) years. All measures at all four test sites showed high within-subject reliability: cold pain thresholds r = 0.92-0.95; pain rating r = 0.93-0.97; McGill pain quality indices r = 0.87-0.85. In contrast, all measures showed wide between-subject variance (CV% between 51.4% and 92.5%). Upper limb sites were consistently more sensitive than lower limb sites, but equally reliable. Females showed elevated cold pain thresholds, although similar pain intensity and quality to males. Females were also more reliable and showed lower variance for all measures. Thus, although there was clear population variation, response to cold for healthy individuals was found to be highly reliable, whether measured as pain threshold, pain intensity or sensation quality. A comprehensive approach to cold response testing therefore may add validity and improve acceptance of this potentially important pain measure.

Subjects with Knee Osteoarthritis Exhibit Widespread Hyperalgesia to Pressure and Cold.

Hyperalgesia to mechanical and thermal stimuli are characteristics of a range of disorders such as tennis elbow, whiplash and fibromyalgia. This study evaluated the presence of local and widespread mechanical and thermal hyperalgesia in individuals with knee osteoarthritis, compared to healthy control subjects. Twenty-three subjects with knee osteoarthritis and 23 healthy controls, matched for age, gender and body mass index, were recruited for the study. Volunteers with any additional chronic pain conditions were excluded. Pain thresholds to pressure, cold and heat were tested at the knee, ipsilateral heel and ipsilateral elbow, in randomized order, using standardised methodology. Significant between-groups differences for pressure pain and cold pain thresholds were found with osteoarthritic subjects demonstrating significantly increased sensitivity to both pressure (p = .018) and cold (p = .003) stimuli, compared with controls. A similar pattern of results extended to the pain-free ipsilateral ankle and elbow indicating widespread pressure and cold hyperalgesia. No significant differences were found between groups for heat pain threshold, although correlations showed that subjects with greater sensitivity to pressure pain were also likely to be more sensitive to both cold pain and heat pain. This study found widespread elevated pain thresholds in subjects with painful knee osteoarthritis, suggesting that altered nociceptive system processing may play a role in ongoing arthritic pain for some patients.

Abnormal quantitative sensory testing is associated with persistent pain one year after TKA.

BACKGROUND: Up to 15% of patients report at least moderate persistent pain after TKA. Such pain may be associated with the presence of widespread hyperalgesia and neuropathic-type pain. QUESTIONS/PURPOSES: We asked if there was a difference among patients who report moderate to severe pain or no pain at least 12 months after TKA regarding (1) pressure pain threshold, (2) thermal (cold/heat) pain and detection thresholds, and (3) self-reported neuropathic pain. PATIENTS AND METHOD: Fifty-three volunteers were recruited from patients reporting no pain or moderate to severe pain, according to the Knee Society Score©. Differences between the moderate-to-severe and no-pain groups regarding pressure pain, heat and cold thresholds, and self-reported neuropathic-type pain were analyzed using independent t-tests. RESULTS: Patients in the moderate-to-severe pain group exhibited reduced pressure pain threshold in the knee with the TKA (p=0.025) and at the elbow (p=0.002). This group also showed greater pain sensitivity to cold at the knee (p=0.008) and elbow (p=0.010), and increased heat pain sensitivity at the elbow (p=0.032). Cold and heat detection thresholds were impaired in this group at the elbow (cold, p=0.034; heat, p=0.010), although only heat detection was impaired at the knee (p=0.009). The moderate-to-severe pain group also reported more neuropathic-type pain (p=0.001). CONCLUSION: Persistent pain after TKA was associated with widespread pressure, cold hyperalgesia, and greater neuropathic-type pain. LEVEL OF EVIDENCE: Level III, prognostic study.

Analysis of meaningful conditioned pain modulation effect in a pain-free adult population.

UNLABELLED: Conditioned pain modulation (CPM) encompasses the effects of inhibitory and facilitatory pain modulatory systems and is inefficient in some chronic pain states. A proportion of healthy subjects also exhibit little or no CPM, perhaps suggesting that inherent factors such as gender or genetics may be influential. However, there is no consensus on how best to determine a meaningful CPM effect. This study aimed to determine the proportion of pain-free subjects exhibiting a meaningful CPM effect. Analyses of associations between 5HTTLPR (serotonin transporter-linked polymorphic region) polymorphisms on the serotonin transporter gene (SLC6A4), gender, and CPM effect were also carried out. A total of 125 healthy subjects (47 male; 78 female) underwent pressure pain threshold testing before, during, and after a cold pressor conditioning stimulus. A buccal cell sample was collected for analysis of 5HTTLPR genotype. Meaningful CPM effect was determined as an increase in pressure pain threshold values from baseline greater than the inherent error of measurement, calculated as 5.3%. During the conditioning stimulus, 116 subjects (92.8%) exhibited a CPM effect whereas 9 did not. CPM effect did not differ significantly between genders or between 5HTTLPR genotypes. This provides a clear basis on which to determine the proportion of patients with a chronic pain disorder that exhibit a meaningful CPM effect. PERSPECTIVE: This study proposes a method for calculating meaningful CPM effect and reports the proportion and magnitude of effect elicited in a large sample. Associations between CPM, gender, and genotype were also analyzed. Clarification of normal CPM response may help to elucidate the mechanisms driving CPM inefficiency in chronic pain.

Identifying culturally appropriate strategies for coronary heart disease secondary prevention in a regional Aboriginal Medical Service.

Aboriginal Australians experience high rates of coronary heart disease (CHD) at an early age, highlighting the importance of effective secondary prevention. This study employed a two-stage process to evaluate CHD management in a regional Aboriginal Medical Service. Stage 1 involved an audit of 94 medical records of clients with documented CHD using the Audit and Best Practice in Chronic Disease approach to health service quality improvement. Results from the audit informed themes for focus group discussions with Aboriginal Medical Service clients (n=6) and staff (n=6) to ascertain barriers and facilitators to CHD management. The audit identified that chronic disease management was the focus of appointments more frequently than in national data (P<0.05), with brief interventions for lifestyle modification occurring at similar or greater frequency. However, referrals to follow-up support services for secondary prevention were lower (P<0.05). Focus groups identified psychosocial factors, systemic shortcomings, suboptimal medication use and variable awareness of CHD signs and symptoms as barriers to CHD management, whereas family support and culturally appropriate education promoted health care. To optimise CHD secondary prevention for Aboriginal people, health services require adequate resources to achieve best-practice systems of follow up. Routinely engaging clients is required to ensure services meet diverse community needs.

An exploration of the relationship between back muscle endurance and familial, physical, lifestyle, and psychosocial factors in adolescents and young adults.

STUDY DESIGN: Cross-sectional investigation. OBJECTIVE: To explore the relationship between back muscle endurance (BME) and a range of familial, physical, lifestyle, and psychosocial variables in adolescents and young adults. BACKGROUND: There is evidence that low back pain interventions which focus on improved BME are effective. However, the mechanisms associated with BME performance in adolescents and young adults are largely unclear. In particular, the potential familial relationship between parents and their children remains unexplored. METHODS: This study utilized a subset of participants from the Joondalup Spinal Health Study cohort. One hundred nine children (47 boys, 62 girls) and 101 parents (39 fathers, 62 mothers) completed a series of physical, lifestyle, and psychosocial assessments. The univariable relationship between each covariate and BME was explored. Those found to have an association with child BME (P<.2) were included in an initial multivariable model and sequentially removed, until all remaining covariates were statistically significant (P<.05). RESULTS: Mothers' BME performance was related to children's performance, accounting for 14.4% of the variance in the children's BME. Fathers' BME performance had a similar, albeit nonsignificant effect. Children's sitting trunk angle, pain sensitivity, percent trunk fat, waist girth, and body mass index were associated with their BME performance, accounting for between 5.2% and 20.9% of BME. CONCLUSIONS: The final multivariable model, including mother's BME, percent trunk fat, and sitting trunk angle, explained 28% of the variance in BME performance, suggesting that for successful BME intervention a range of multidimensional variables should be considered.

The initial effects of knee joint mobilization on osteoarthritic hyperalgesia.

Physiotherapists often employ lower limb joint mobilization to reduce pain and increase function. However, there is little experimental data confirming its efficacy. The purpose of this study was to investigate the initial effects of accessory knee joint mobilization on measures of pain and function in individuals with knee osteoarthritis. The study employed a double-blind, controlled, within-subjects repeated-measures design. Thirty-eight subjects with mild to moderate knee pain participated. The effects of a 9-min, non-noxious, AP mobilization of the tibio-femoral joint were compared with manual contact and no-contact interventions. Pressure pain threshold (PPT) and 3-m 'up and go' time were measured immediately before and after each intervention. Results demonstrated a significantly greater mean (95% CI) percentage increase in PPT following knee joint mobilization (27.3% (20.9-33.7)) than after manual contact (6.4% (0.4-12.4)) or no-contact (-9.6% (-20.7 to 1.6)) interventions. Knee joint mobilization also increased PPT at a distal, non-painful site and reduced 'up and go' time significantly more (-5% (-9.3 to 0.8)) than manual contact (-0.4% (-4.2 to 3.5)) or no-contact control (+7.9% (2.6-13.2)) interventions. This study therefore provides new experimental evidence that accessory mobilization of an osteoarthritic knee joint immediately produces both local and widespread hypoalgesic effects. It may therefore be an effective means of reducing pain in this population.