Improving general practice management of patients with chronic musculoskeletal pain: Interdisciplinarity, coherence, and concerns.

OBJECTIVES: Management of patients with chronic musculoskeletal pain (CMP) remains a challenge in general practice. The general practitioner (GP) often experiences diagnostic uncertainty despite frequently referring patients with CMP to specialized departments. Therefore, it remains imperative to gain insights on how to optimize and reframe the current setup for the management of patients with CMP. The objective was to explore GP's perspectives on the challenges, needs, and visions for improving the management of patients with CMP. METHODS: A qualitative study with co-design using the future workshop approach. Eight GPs participated in the future workshop (five females). Insights and visions emerged from the GP's discussions and sharing of their experiences in managing patients with CMP. The audio-recorded data were subjected to thematic text analysis. RESULTS: The thematic analysis revealed four main themes, including (1) challenges with current pain management, (2) barriers to pain management, (3) the need for a biopsychosocial perspective, and (4) solutions and visions. All challenges are related to the complexity and diagnostic uncertainty for this patient population. GPs experienced that the patients' biomedical understanding of their pain was a barrier for management and underlined the need for a biopsychosocial approach when managing the patients. The GPs described taking on the role of coordinators for their patients with CMP but could feel ill-equipped to handle diagnostic uncertainty. An interdisciplinary unit was recommended as a possible solution to introduce a biopsychosocial approach for the examination, diagnosis, and management of the patient's CMP. CONCLUSIONS: The complexity and diagnostic uncertainty of patients with CMP warrants a revision of the current setup. Establishing an interdisciplinary unit using a biopsychosocial approach was recommended as an option to improve the current management for patients with CMP.

A simple, bed-side tool to assess evoked pressure pain intensity.

OBJECTIVES: Existing equipment for quantitative sensory testing is generally expensive and not easily applicable in a clinical setting thus simple bed-side devices are warranted. Pressure hyperalgesia is a common finding in patients with musculoskeletal pain and an experimental model is delayed-onset muscle soreness (DOMS). DOMS is characterised by muscle hyperalgesia and some studies report facilitation of temporal summation of pain. This study aimed to detect DOMS induced muscle hyperalgesia and temporal summation of pain using a newly developed bed-side quantitative sensory testing device to deliver standardised pressure. METHODS: Twenty-two healthy participants participated in two sessions with the second session approximately 48 h after baseline. Pressure pain intensities were assessed from the gastrocnemius muscle with four probes calibrated to apply 2, 4, 6 and 8 kg, respectively. Temporal summation of pain (10 stimuli delivered at 0.5 Hz using the 6 kg probe) intensities were assessed from the same location. DOMS was evoked in the gastrocnemius muscle by an eccentric exercise. Sleepiness and physical activity were measured with the Epworth Sleepiness Scale and the Global Physical Activity Questionnaire to investigate if they were associated with the quantitative sensory testing measures. RESULTS: Pressure pain intensity was significantly increased 48 h after induction of DOMS when compared to baseline for all four probes (p<0.05). Temporal summation of pain was not statistically significant affected by DOMS and sleep quality and physical activity did not associate with any of the measures. CONCLUSIONS: This study introduces a simple, bed-side assessment tool for the assessment of pressure pain intensity and hence hyperalgesia and temporal summation of pain.

Five-year follow-up of patients with knee osteoarthritis not eligible for total knee replacement: results from a randomised trial.

OBJECTIVES: The main objective was to investigate 5-year outcomes in patients with knee osteoarthritis, randomised to one of two non-surgical treatments. SETTING: Two outpatient clinics. PARTICIPANTS: At baseline, 100 patients with radiographic and symptomatic knee osteoarthritis not found eligible for knee replacement (KR) were included. Main exclusion criteria were average score above 75 of the Knee injury and Osteoarthritis Outcome Score (KOOS) subscales pain, symptoms, function of daily living and quality of life; KOOS4 and average knee pain the previous week greater than 60 mm on a 100 mm visual analogue scale. INTERVENTIONS: Patients were randomised to supervised non-surgical treatment consisting of patient education, supervised exercise, weight loss, insoles, and pain medication (the MEDIC treatment) or written advice. The 12-week MEDIC treatment included patient education, neuromuscular exercise, insoles and a dietary weight loss programme and/or pain medication if needed and written advice consisted of two leaflets. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was 5-year mean change for KOOS4. Secondary outcomes included KOOS subscales, self-reported health, usage of pain medication and self-reported physical activity. RESULTS: Thirty-nine (78%) and 36 (72%) from the MEDIC and written advice groups responded at 5 years. There were no between-group differences in KOOS4 (difference 5.3 (95% CI -1.5 to 12.1) or any secondary outcomes. However, the 95% CI included the minimal clinically important difference for the main outcome.Seventy-six percent of the MEDIC group and 66% of the written advice group experienced clinically important improvements in KOOS4.Fifteen patients (30%) from the MEDIC group and 17 (34%) from the written advice group received KR in the index knee. Undergoing KR did not result in a statistically significant greater improvement in KOOS4 (difference 6.1 (95% CI -1.1 to 13.4). CONCLUSIONS: No statistically significant differences between supervised non-surgical treatment and written advice were demonstrated at 5 years. Most patients experienced clinically important improvements, irrespective of initial treatment strategy or KR. TRIAL REGISTRATION NUMBER: NCT01535001; ClinicalTrials.gov.

A novel clinical applicable bed-side tool for assessing conditioning pain modulation: proof-of-concept.

Background and aims In recent years, focus on assessing descending pain modulation or conditioning pain modulation (CPM) has emerged in patients with chronic pain. This requires reliable and simple to use bed-side tools to be applied in the clinic. The aim of the present pilot study was to develop and provide proof-of-concept of a simple clinically applicable bed-side tool for assessing CPM. Methods A group of 26 healthy volunteers participated in the experiment. Pressure pain thresholds (PPT) were assessed as test stimuli from the lower leg before, during and 5 min after delivering the conditioning tonic painful pressure stimulation. The tonic stimulus was delivered for 2 min by a custom-made spring-loaded finger pressure device applying a fixed pressure (2.2 kg) to the index finger nail. The pain intensity provoked by the tonic stimulus was continuously recorded on a 0-10 cm Visual Analog Scale (VAS). Results The median tonic pain stimulus intensity was 6.7 cm (interquartile range: 4.6-8.4 cm) on the 10 cm VAS. The mean PPT increased significantly (P = 0.034) by 55 ± 126 kPa from 518 ± 173 kPa before to 573 ± 228 kPa during conditioning stimulation. When analyzing the individual CPM responses (increases in PPT), a distribution of positive and negative CPM responders was observed with 69% of the individuals classified as positive CPM responders (increased PPTs = anti-nociceptive) and the rest as negative CPM responders (no or decreased PPTs = Pro-nociceptive). This particular responder distribution explains the large variation in the averaged CPM responses observed in many CPM studies. The strongest positive CPM response was an increase of 418 kPa and the strongest negative CPM response was a decrease of 140 kPa. Conclusions The present newly developed conditioning pain stimulator provides a simple, applicable tool for routine CPM assessment in clinical practice. Further, reporting averaged CPM effects should be replaced by categorizing volunteers/patients into anti-nociceptive and pro-nociceptive CPM groups. Implications The finger pressure device provided moderate-to-high pain intensities and was useful for inducing conditioning stimuli. Therefore, the finger pressure device could be a useful bed-side method for measuring CPM in clinical settings with limited time available. Future bed-side studies involving patient populations are warranted to determine the usefulness of the method.

Neuromuscular exercise and pain neuroscience education compared with pain neuroscience education alone in patients with chronic pain after primary total knee arthroplasty: study protocol for the NEPNEP randomized controlled trial.

BACKGROUND: Total knee arthroplasty (TKA) is considered an effective treatment for pain relief and improved physical performances in end-stage knee osteoarthritis. However, several studies have reported less favorable outcomes after TKA with chronic pain rates of approximately 20%. Exercise might be an effective treatment strategy for chronic pain following TKA, but no randomized controlled trials have evaluated its effect. Therefore, the purpose of this randomized controlled trial is to investigate whether a 12-week neuromuscular exercise (NEuroMuscular EXercise training program for patients with knee or hip osteoarthritis assigned for total joint replacement; NEMEX-TJR) program combined with pain neuroscience education (PNE) provides greater pain relief and improvement in physical performances than PNE alone at 12 months follow-up in a population of patients with chronic pain after primary TKA. METHODS: For this randomized controlled superiority trial, 120 patients with moderate-to-severe chronic pain after TKA are recruited from Aalborg University Hospital, Denmark. Patients are randomly assigned in a 1:1 ratio to one of two interventions: (a) NEMEX-TJR twice weekly for 12 weeks combined with two sessions of PNE or (b) two sessions of PNE given over 6 weeks. Assessment is performed at baseline before intervention and at 3, 6, and 12 months after initiation of the intervention. Outcome assessors are blinded toward group allocation. The primary outcome is the change in the Knee Injury and Osteoarthritis Outcome Score4 (KOOS4), defined as the mean score for the KOOS subscales pain, symptoms, activities of daily living, and quality of life. Secondary outcomes include all KOOS subscale scores and scores for PainDETECT, the Fear-Avoidance Beliefs Questionnaire, Global Perceived Effect, the Pain Catastrophizing Scale, pain intensities, temporal summation, conditioned pain modulation, and pressure pain thresholds. Physical performances are measured with walking, stair climbing, and chair standing tests as well as tests of muscle strength and power. DISCUSSION: The findings will be useful in establishing effective treatment strategies for chronic pain after TKA. The randomized controlled trial involves rigorous scientific methods and uses clinically applicable interventions. The study interventions are conducted in clinical settings, thereby enhancing the possibility of future implementation of the treatments in the health care systems. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03886259. Registered 22 March 2019. Ethics committee registration: N-20180046.

Intensive, personalized multimodal rehabilitation in patients with primary or revision total knee arthroplasty: a retrospective cohort study.

BACKGROUND: Recent evidence has shown that many patients suffer from persistent pain and impaired function after primary or revision total knee arthroplasty (TKA). Post-surgical complications may in addition decrease physical performances and lead to more pain and impacted quality of life.The purpose of the study was to assess the changes in pain intensity and functional capacity among patients with post-surgical complications after TKA three weeks of intensive, personalized multimodal rehabilitation. METHODS: A retrospective cohort study consisting of 217 patient of which 166 had primary TKA and 51 had revision TKA was conducted. On average, primary TKA patients and revision TKA patients were 3.7 and 2.7 months post-surgical, respectively. All patients have had post-surgical complications and were referred to an inpatient rehabilitation department, where they received a personalized three-week intensive, multimodal rehabilitation protocol. The rehabilitation consisted of sessions targeting neuromuscular function, postural control, and flexibility, sessions focusing on improving muscle strength and cardiovascular function and sessions with focus on gait retraining. The frequency of training was 2-4 sessions/day. The primary outcome was the Knee injury and Osteoarthritis Outcome Score (KOOS) and secondary outcomes were pain intensities measured using numerical rating scale, 6 min. walking test, stair-climbing test and range of motion for knee flexion and extension. Outcome measures were assessed at baseline upon referral and at follow-up before discharge. RESULTS: All outcomes, except pain at rest in the revision group, improved significantly. KOOS subscales, improved 8.5 to 14.2 in the primary TKA group (p < 0.001) and 6.9 to 10.8 in the revision group (p < 0.001). For the TKA group, effect sizes were medium-to-large for all KOOS subscales, 6 min. walking test, stair-climbing test, and pain intensity during activity. For the revision group, effect sizes were medium-to-large for KOOS subscales symptoms and activity of daily living, 6 min. walking test, stair-climbing test, and knee flexion. CONCLUSION: Patients with post-surgical complications after primary or revision TKA experienced clinical relevant improvement in self-reported outcomes, pain relief, and improved physical performances after three weeks of personalized multimodal rehabilitation. The results suggest that an intensive, multimodal approach might be useful to obtain clinically relevant improvements.

Wireless multichannel vibroarthrographic recordings for the assessment of knee osteoarthritis during three activities of daily living.

BACKGROUND: Variations in the internal pressure distribution applied to cartilage and synovial fluid explain the spatial dependencies of the knee vibroarthrographic signals. These spatial dependencies were assessed by multi-channel recordings during activities of daily living in patients with painful knee osteoarthrosis. METHODS: Knee vibroarthrographic signals were detected using eight miniature accelerometers, and vibroarthrographic maps were calculated for the most affected knee of 20 osteoarthritis patients and 20 asymptomatic participants during three activities: (i) sit to stand, (ii) stairs descent, and (iii) stairs ascent in real life conditions. Vibroarthrographic maps of average rectified value, variance of means squared, form factor, mean power frequency, % of recurrence and, % of determinism were obtained from the eight VAG recordings. FINDINGS: Higher average rectified value and lower % of recurrence were found in knee osteoarthritis patients compared with asymptomatic participants. All vibroarthrographic parameters, except for % of recurrence, differentiated the type of activity. Average rectified value, variance of means squared, form factor, and % of determinism were lowest while mean power frequency was highest during sit-to-stand compared with stairs ascent and descent. INTERPRETATION: Distinct topographical vibroarthrographic maps underlined that the computed parameters represent unique features. The present study demonstrated that wireless multichannel vibroarthrographic recordings and the associated topographical maps highlighted differences between (i) knee osteoarthritis patients and asymptomatic participants, (ii) sit to stand, stairs descent and ascent and (iii) knee locations. The technique offers new perspectives for biomechanical assessments of physical functions of the knee joint in ecological environment.

Development of a new bed-side-test assessing conditioned pain modulation: a test-retest reliability study.

Background and aims Conditioned pain modulation (CPM) is of considerable interest within pain research. Often CPM testing is conducted in experimental settings using complicated instrumentation, thus challenging the implementation in clinical settings. Being able to assess CPM in a fast and reliable way in clinical settings could lead to a new diagnostic tool allowing improved profiling of pain patients. Methods A test-retest reliability study and a methodological development study were conducted based on different populations. The reliability study included 22 healthy subjects, mean age 23.6 years (SD: 2.4) and the methodological study included 29 healthy subjects, mean age 21.5 years (SD: 1.6). As painful phasic test stimulus, a 6-10 kg handheld, spring-based pressure algometer was applied perpendicularly to the muscle belly of the tibialis anterior muscle for 10 s and as painful tonic conditioning stimulus, 1-2 standard clamps, inducing a force of 1.3 kg, were applied extra-segmentally at the ipsilateral earlobe for 60-120 s. Four different test protocols were evaluated, of which one protocol was investigated for reliability. Test protocol 1 used a 6 kg pressure algometer as painful phasic test stimulus and a single clamp applied for 60 s as painful tonic conditioning stimulus. Test protocol 2 used a 10 kg pressure algometer as painful phasic test stimulus, and two clamps applied for 60 s as painful tonic conditioning stimulus. Test protocol 3 used a 10 kg pressure algometer as painful phasic test stimulus and a single clamp applied for 120 s as painful tonic conditioning stimulus. Test protocol 4 used a 6 kg pressure algometer as painful phasic test stimulus and a single clamp applied for 120 s as painful tonic conditioning stimulus. Results None of the stimuli caused any adverse events, e.g. bruises. In the reliability study (test protocol (1), non-significant CPM effects of 0.3 (SD: 1.6) and 0.2 (SD: 1.0) were observed in session 1 and 2, respectively. The intra-class correlations were 0.67 and 0.72 (p = < 0.01) and limits of agreement (LoA) ranged from -2.76 to 3.31. Non-significant CPM effects of 0.2 (SD: 1.0), -0.1 (SD: 1.1), and 0.0 (SD: 1.2) were observed for test protocol 2, 3, and 4, respectively). Conclusions The bedside test developed for investigating CPM was feasible and easy to use in healthy volunteers. No significant CPM effects were measured and a large variation in CPM effect ranging from -0.14 to 0.32 was observed. Intra-class correlation (ICC) values for the pressure algometer were interpreted as "good relative reliability" (test protocol 1), and LoA revealed a somewhat low absolute reliability. Implications The pressure algometer provided reproducible measurements and was useful for inducing phasic test stimuli. Since no significant CPM effects were detected, no recommendations for the bedside test can yet be made. Further examinations will have to establish if the "one size fits all" application of both test and conditioning stimuli is useful. Future bedside studies involving patient populations are warranted to determine the usefulness of the method.

Muscle strength and functional performance is markedly impaired at the recommended time point for sport return after anterior cruciate ligament reconstruction in recreational athletes.

PURPOSE: To examine potential deficits in muscle strength or functional capacity when comparing (1) an ACL reconstructed group to matched healthy controls, (2) the ACL reconstructed leg to the non-injured leg and (3) the non-injured leg to matched healthy controls, at the time-point of recommended sport return 9-12months post-surgery. METHODS: Sixteen patients (male-female ratio: 9:7) 9-12months post ACL reconstruction and sixteen age and sex matched healthy controls were included. Outcome measures included maximal knee extensor (KE) and knee flexor (KF) dynamometry, including measurement of rate of force development, functional capacity (counter movement jump (CMJ) and single distance hop (SDH)) and the Lysholm score. RESULTS: Compared to the control group, maximal KE and KF muscle strength were impaired in the ACL reconstructed leg by 27-39% and 16-35%, respectively (p<.001). Also, impairments of both CMJ (38%) and SDH (33%) were observed (p<.001). Rate of force development for KE were reduced in the ACL group compared to the control group (p<.001). Similarly, the KE and KF muscle strength, CMJ and SDH of the ACL reconstructed leg were impaired, when compared to the non-injured leg by 15-23%, 8-20%, 23% and 20%, respectively (p<.05). CONCLUSION: Muscle strength and functional capacity are markedly impaired in the ACL reconstructed leg of recreationally active people 9-12months post-surgery when compared to healthy matched controls and to their non-injured leg. This suggests that objective criteria rather than "time-since-surgery" criteria should guide return to sport.