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

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

Comparing physical therapy students' attitudes and beliefs regarding chronic low back pain and knee osteoarthritis: an international multi-institutional comparison between 2013 and 2020 academic years.

BACKGROUND: In 2013, physical therapy students demonstrated low guideline-adherent recommendations regarding chronic low back pain (CLBP) for spinal pathology, activity, and work. OBJECTIVES: To assess the differences in physical therapy students' attitudes, beliefs, and adherence to guideline recommendations regarding CLBP and knee osteoarthritis between 2013 and 2020. METHODS: In 2013 and 2020, second and fourth-year physical therapy students were recruited from 6 Belgian and 2 Dutch institutions. Attitudes and beliefs regarding CLBP and knee OA were evaluated using the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT), the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS), and a questionnaire regarding therapeutic exercise and knee osteoarthritis. A clinical vignette was used to measure guideline-adherent recommendations regarding spinal pathology, activity, and work. RESULTS: In 2013, 927 second-year and 695 fourth-year students; in 2020, 695 second-year and 489 fourth-year students; were recruited to participate in the study. Compared to 2013, students had less biomedical and stronger biopsychosocial attitudes and beliefs regarding CLBP, more guideline-adherent recommendations for activity, and more biopsychosocial beliefs regarding the benefits of exercise for patients with knee osteoarthritis in both the second and fourth year. Only fourth-year students in 2020 scored significantly better on HC-PAIRS and guideline-adherent recommendation relating to spinal pathology. No differences were found regarding work recommendations. CONCLUSIONS: Between 2013 and 2020, physical therapy students made a positive shift towards a more biopsychosocial approach to CLBP and knee osteoarthritis management. Guideline-adherent recommendations for CLBP concerning activity improved, however, concerning work and spinal pathology, it remained low.

Assessment of functional respiratory complaints and related factors in people with hypermobile Ehlers-Danlos syndrome: Cross-sectional study.

BACKGROUND: Hypermobile Ehlers-Danlos Syndrome (hEDS) is the most common type of EDS. Apart from joint symptoms, people with hEDS have systemic manifestations as a chronic modification of the breathing pattern (functional respiratory complaints (FRCs)) and mental disorders. However, the prevalence of FRCs, and its relationship with mental disorders, have not yet been estimated for this population. OBJECTIVES: To assess the FRCs, central sensitization, disease perception, depression, and anxiety in people with hEDS from Belgium; and to identify the clustering of FRCs and determine any association with the characteristics assessed for this sample. METHODS: This cross-sectional study assessed socio-demographic characteristics, Nijmegen questionnaire (NQ), Central Sensitization Inventory (CSI), Brief Illness Perception Questionnaire, and the Hospital Anxiety and Depression Scale (HADS) in people with hEDS from Belgium. A two-step cluster analysis was performed to identify clusters according to NQ, and to understand how the other questionnaires are grouped among these clusters. RESULTS: The Spearman correlation coefficients showed that all the outcomes were significantly and positively correlated with each other (p<0.05). Furthermore, 84.9% of the sample had symptoms suggestive of FRCs, and 54.3% had probable anxiety. Three clusters were grouped (no FRCs, mild FRCs, and severe FRCs), with NQ, HADS-D and CSI-part A being the variables that contributed the most. People from cluster of severe FRCs got the worst scores for all the questionnaires. CONCLUSION: FRCs, central sensitization, depression, and anxiety are prevalent comorbidities in people with hEDS. Moreover, those people with FRCs had worse results in the investigated parameters, with depression being the variable that contributed the most to the clusters of FRCs. Consequently, investigating mechanisms for these co-occurring symptom profiles may improve our understanding of pathogenesis and indicate new management strategies to alleviate these symptoms and lead to the development of more effective care for persons with hEDS.

Chronic temporomandibular disorders are associated with higher propensity to develop central sensitization: a case-control study.

ABSTRACT: Temporomandibular disorders (TMD) include a group of musculoskeletal disorders that may involve increased responsiveness of nociceptive neurons in the central nervous system (ie, central sensitization). To test this hypothesis further, this study examined whether, as compared with healthy subjects, patients with chronic TMD have a greater propensity to develop secondary mechanical hyperalgesia-a phenomenon that can be confidently attributed to central sensitization. In this case-control study, we assessed the area of secondary mechanical hyperalgesia induced experimentally by delivering high-frequency electrical stimulation (HFS) to the volar forearm skin in 20 participants with chronic TMD and 20 matched healthy controls. High-frequency electrical stimulation consisted in 12 trains of constant-current electrical pulses (5 mA) delivered at 42 Hz. The area of secondary mechanical hyperalgesia was evaluated 30 minutes after applying HFS. The area of secondary mechanical hyperalgesia induced by HFS was on average 76% larger in the chronic TMD group (M = 67.7 cm 2 , SD = 28.2) than in the healthy control group (M = 38.4 cm 2 , SD = 14.9; P = 0.0003). Regarding secondary outcomes, there was no group difference in the intensity of secondary mechanical hyperalgesia, but allodynia to cotton after HFS was more frequent in the chronic TMD group. To the best of our knowledge, this is the first study to show that individuals with chronic TMD have an increased propensity to develop secondary hyperalgesia in a site innervated extratrigeminally. Our results contribute to a better understanding of the pathophysiology of chronic TMD.

Relationship Between Leisure Time Physical Activity, Weight, and the Onset and Persistence of Nonspecific Neck Pain: A Systematic Review.

OBJECTIVE: To study the relationships between weight, leisure time physical activity (PA), and the onset and persistence of neck pain in adults with nonspecific neck pain (NSNP). DESIGN: Etiology and prognosis systematic review. LITERATURE SEARCH: Five databases (PubMed, Scopus, Embase, Cochrane Library, PsycINFO) were searched from January 2010 to November 2021. STUDY SELECTION CRITERIA: Case-control or cohort studies assessing the relationship between the onset and the persistence of NSNP, weight, and leisure time PA in healthy adults or adults with NSNP at baseline. DATA SYNTHESIS: Use of the "vote counting based on direction of effects" and qualitative synthesis. RESULTS: Nine articles were included (20 350 participants, range 86-11 391), four on the onset and five on the persistence of NSNP. Methodological quality varied from poor to good according to the Newcastle-Ottawa Scale. For the onset and the persistence of NSNP, there was very low certainty evidence for modest associations suggesting a decreased risk with higher levels of leisure time PA and an increased risk in people with overweight and obesity. CONCLUSION: The risk for onset and persistence of NSNP may be lower in more active people and higher in people with overweight and obesity. Results should be interpreted cautiously and should not be generalized to populations other than workers. J Orthop Sports Phys Ther 2022;52(12):777-791. Epub: 12 August 2022. doi:10.2519/jospt.2022.11137.

Evidence for alterations to dynamic quantitative sensory tests in patients with chronic temporomandibular myalgia: A systematic review of observational studies with meta-analysis.

BACKGROUND: Conflicting results exist between somatosensory profiles of patients with temporomandibular myalgia (TMDm). The objective of this review was to examine whether adults with TMDm show altered responses to dynamic quantitative sensory tests compared with healthy controls. METHODS: We searched five electronic databases for studies, excluding those without suitable controls or where TMDm was associated with confounding non-musculoskeletal disorders. Risk of bias was assessed with the SIGN case-control study checklist. Findings were structured around dynamic quantitative sensory tests and their localization. Where possible, we performed meta-analysis with a random inverse variance model to compare patients with TMDm and healthy controls. Statistical heterogeneity was estimated with Chi² test and inconsistency index, I². RESULTS: We extracted data from 23 studies comprising 1284 adults with chronic TMDm and 2791 healthy controls. Risk of bias was assessed as high for 20 studies. Mechanical temporal summation, the most studied phenomenon (14 studies), is increased in the upper limb of patients with TMDm (SMD = 0.43; 95% CI: .11 to .75; p = .009) but not in the jaw area (p = .09) or in the cervical area (p = .29). Very little evidence for altered thermal temporal summation (five studies), conditioned pain modulation (seven studies), exercise-induced hypoalgesia (two studies), placebo analgesia (two studies), stress-induced hypoalgesia (one study) and offset analgesia (one study) was found. DISCUSSION: A major limitation of this review was the risk of bias of included studies. Future studies would benefit from following methodological guidelines and consideration of confounding factors.

Misconceptions of physical therapists and medical doctors regarding the impact of lifting a light load on low back pain.

BACKGROUND: A common misconception about low back pain (LBP) is that the spine is weak and that lumbar flexion should be avoided. Because the beliefs of health-care professionals (HCPs) influence patients, it is important to understand the attitudes of health care professionals towards LBP and lifting. OBJECTIVES: To assess and compare the perceptions of different categories of HCPs regarding the safety of specific movement strategies used to lift a light load, and their beliefs regarding back pain. The secondary aim was to determine whether certain factors influenced the beliefs of HCPs. METHODS: Data were collected via an electronic survey. Student and qualified physical therapists (PTs), medical students, and general practitioner (GP) trainees were included. The questionnaire included eight photographs, depicting eight different strategies to lift a light load. Respondents were requested to select the strategy(s) they considered as "unsafe" to use for asymptomatic people with a previous history of LBP and people with chronic LBP. Beliefs and attitudes towards LBP were evaluated using the Back Pain Attitudes Questionnaire (Back-PAQ). RESULTS: Questionnaires from 1005 participants were included. Seventy percent of qualified PTs considered none of the strategies as harmful (versus 32% of PT students, 9% of GP trainees and 1% of medical students). Qualified PTs had higher Back-PAQ scores (mean ± SD: 13.6 ± 5.5) than PT students (8.7 ± 5.7), GP trainees (5.9 ± 5.9) and medical students (4.1 ± 5.2), indicating less misconceptions regarding LBP. Having LBP negatively influenced beliefs while taking a pain education course positively influenced beliefs. CONCLUSION: Misconceptions regarding LBP and the harmfulness of lifting a light load with a rounded back remain common among HCPs, particularly medical doctors.

The mouth-opening muscular performance in adults with and without temporomandibular disorders: A systematic review.

BACKGROUND: The mouth-opening muscular performance in patients with temporomandibular disorders (TMDs) is unclear. Understanding the impairments of this muscle group within specific TMDs is important to develop proper management strategies. OBJECTIVE: To characterise the mouth-opening muscular performance in adults with and without TMDs. METHODS: PubMed, EMBASE, CINAHL, Scopus, Web of Science and Cochrane databases were searched from inception to 12 November 2020. Bibliographies were searched for additional articles, including grey literature. Case-control, cross-sectional and interventional studies reporting mouth-opening muscular strength and/or endurance were included. Risk of bias was assessed by the SIGN checklist for case-control studies and by the NIH quality assessment tool for cross-sectional studies. Results were pooled with a random-effects model. Confidence in cumulative evidence was determined by means of the GRADE guidelines. RESULTS: Fourteen studies were included; most were rated as having a moderate risk of bias. Only three studies assessed patients with TMDs and the other 11 assessed healthy adults. Significant sex differences in muscular performance were found for healthy adults in the review (strength deficit for females versus males). There was a significant reduction in maximal mouth opening performance (strength and endurance) in the three studies that assessed patients with temporomandibular disorders. CONCLUSION: Sex plays a significant role in maximal mouth opening strength. There is a lack of reliable data on the normal mouth-opening strength and endurance of healthy adults as well as for patients with TMDs. IMPLICATIONS: Lack of reliable TMDs patient data and comparable healthy adult data highlight future direction for research.

Effectiveness of manual therapy applied to craniomandibular structures in temporomandibular disorders: A systematic review.

BACKGROUND: Within physical therapy, manual therapy is known to be effective for managing temporomandibular disorders (TMDs). However, manual therapy is a broad term including different approaches applied to different body regions. AIMS: This is the first systematic review that aims to evaluate the effectiveness of manual therapy applied specifically to the craniomandibular structures (Cranio-Mandibular Manual Therapy [CMMT]) on pain and maximum mouth opening in people with TMD. MATERIAL AND METHODS: This systematic review was developed based on a pre-determined published protocol which was prospectively registered with PROSPERO (CRD42019160213). A search of MEDLINE, Embase, CINAHL, ZETOC, Web of Science, SCOPUS, PEDro, PubMed, Cochrane Library and Best Evidence, EBM reviews-Cochrane Central Register of Controlled Trials, Index to Chiropractic Literature ChiroAccess and Google Scholar databases was conducted from inception until October 2020. Randomised controlled trials comparing the effect of CMMT on pain and maximum mouth opening versus other types of treatment in TMDs were included. Two reviewers independently screened articles for inclusion, extracted data, assessed risk of bias with the revised Cochrane risk of bias tool for randomised trials and evaluated the overall quality of evidence with the Grading of Recommendations, Assessment, Development and Evaluations. RESULTS: A total of 2720 records were screened, of which only 6 (293 participants) satisfied the inclusion criteria. All studies showed some concerns in risk of bias, except for one, which was high risk of bias. The overall quality of evidence was very low for all outcomes because of high heterogeneity and small sample sizes. All studies showed a significant improvement in pain and maximum mouth opening for CMMT from baseline in the mid-term, but only two showed superiority compared to other interventions. Given the high heterogeneity and small sample sizes of the included studies, a quantitative synthesis was not performed. DISCUSSION AND CONCLUSION: There is the need for future high methodology research investigating different manual therapy techniques applied to different regions and different populations (e.g., chronic versus acute TMD) to determine what is most effective for pain and maximum mouth opening in patients with TMDs.

Several low back pain-related misbeliefs are still around in 2020: A cross-sectional survey in Belgium.

BACKGROUND AND PURPOSE: Low back pain (LBP)-related misbeliefs are known to be among risk factors for LBP chronification and for persistence of chronic pain. The main objective of this study was to investigate the current LBP-related beliefs in the general population in Belgium, considering the fact that the last survey in Belgium about the topic was conducted more than 15 years ago. METHODS: A cross-sectional study design was used. Belgian adults (>17 years old) were recruited in the three regions of the country by means of non-probabilistic recruitment methods. Participants were invited to fill in a battery of questionnaires including demographic questions as well as questions about their LBP history and the LBP Beliefs Questionnaire (LBPBQ). RESULTS: A total of 3724 individuals participated in the study. The LBPBQ scores indicated several LBP-related misbeliefs. About 15%-25% of participants still think that imaging tests can always identify the cause of pain and that bed rest is the mainstay of therapy. The majority of the participants think that "unnecessary" movements should be avoided when having LBP (58% of the respondents), and that they should "take it easy" until the pain goes away (69%). Most respondents also had maladaptive/wrong expectations, for example, a systematic worsening with time (65%) and a need for surgery in case of disc herniation (54%). CONCLUSIONS: The present study suggests that in 2020 several LBP-related misbeliefs are still current in Belgium, particularly regarding the vulnerability of the spine. Therefore, further efforts to improve LBP-related beliefs/knowledge in the general population are necessary.

Sensorimotor performance in acute-subacute non-specific neck pain: a non-randomized prospective clinical trial with intervention.

BACKGROUND: The assessment of cervical spine kinematic axial rotation performance is of great importance in the context of the study of neck sensorimotor control. However, studies addressing the influence of the level of provocation of spinal pain and the potential benefit of passive manual therapy mobilizations in patients with acute-subacute non-specific neck pain are lacking. METHODS: A non-randomized prospective clinical trial with an intervention design was conducted. We investigated: (1) the test-retest reliability of kinematic variables during a fast axial head rotation task standardized with the DidRen laser test device in 42 Healthy pain-free Control Participants (HCP) (24.3 years ±6.8); (2) the differences in kinematic variables between HCP and 38 patients with Acute-subacute Non-Specific neck Pain (ANSP) assigned to two different groups according to whether their pain was localized in the upper or lower spine (46.2 years ±16.3); and (3) the effect of passive manual therapy mobilizations on kinematic variables of the neck during fast axial head rotation. RESULTS: (1) Intra-class correlation coefficients ranged from moderate (0.57 (0.06-0.80)) to excellent (0.96 (0.91-0.98)). (2) Kinematic performance during fast axial rotations of the head was significantly altered in ANSP compared to HCP (age-adjusted) for one variable: the time between peaks of acceleration and deceleration (p<0.019). No significant difference was observed between ANSP with upper vs lower spinal pain localization. (3) After the intervention, there was a significant effect on several kinematic variables, e.g., ANSP improved peak speed (p<0.007) and performance of the DidRen laser test (p<0.001), with effect sizes ranging from small to medium. CONCLUSION: (1) The DidRen laser test is reliable. (2) A significant reduction in time between acceleration and deceleration peaks was observed in ANSP compared to HCP, but with no significant effect of spinal pain location on kinematic variables was found. (3) We found that neck pain decreased after passive manual therapy mobilizations with improvements of several kinematic variables. TRIAL REGISTRATION: Registration Number: NCT04407637.

The effectiveness of manual therapy applied to craniomandibular structures in the treatment of temporomandibular disorders: protocol for a systematic review.

BACKGROUND: The term temporomandibular disorder (TMD) includes disorders of the temporomandibular joints (TMJ), masticatory muscles and adjacent tissues. Several studies have examined the effectiveness of manual therapy (MT) for TMDs by evaluating changes in pain and maximum mouth opening (MMO). Nevertheless, the effectiveness of MT exclusively applied to the craniomandibular structures (craniomandibular manual therapy (CMMT)) on pain and TMJ range of motion remains unclear. This review aims to evaluate the effectiveness of CMMT on pain and TMJ range of motion in people with TMDs. METHODS: This protocol is reported in line with the preferred reporting items for systematic reviews and meta-analysis protocols (PRISMA-P). Databases including MEDLINE, Embase, CINAHL, ZETOC, Web of Science, SCOPUS, PEDro, PubMed, Cochrane Library and Best Evidence, EBM reviews-Cochrane Central Register of Controlled Trials, Index to Chiropractic Literature ChiroAccess and Google Scholar will be searched from inception as well as key journals and grey literature. Randomised controlled trials involving adults with TMD that compare the effect of any type of CMMT (e.g. mobilisation) on pain and range of motion with a placebo intervention, controlled care intervention or other types of treatment will be included. Two reviewers will independently screen articles for inclusion, extract data, assess risk of bias (revised Cochrane risk of bias tool) for included studies and evaluate overall quality of evidence (Grading of Recommendations Assessment, Development and Evaluation). A meta-analysis will be conducted if possible. If not, a narrative synthesis will be conducted reporting the effectiveness of CMMT according to disorder type (TMJ disorders, masticatory muscle disorders and mixed disorders). DISCUSSION: In this review, the effectiveness of MT applied to craniomandibular structures for the treatment of TMD will be evaluated. Results will be submitted for publication in a peer-reviewed journal and presented at conferences. We expect our findings will facilitate treatment planning for manual therapists managing patients with TMD and provide future clinical research implications. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019160213.

Stuck in the Middle With You: Why a Broad-Brush Approach to Defining Central Sensitization Does Not Help Clinicians and Patients.

SYNOPSIS: Central sensitization is (1) increasingly interpreted as central nervous system hyperexcitability that accounts for a general increase in sensitivity, and (2) used to explain a variety of pain and nonpain symptoms. In this commentary, we argue that such a broad interpretation might not be clinically useful because it fails to distinguish one patient from another based on pathophysiological mechanisms and does not facilitate tailored treatment. We recommend that clinicians use a person-centered approach when assessing and managing patients, considering the different interacting processes/mechanisms that can contribute to a patient's clinical presentation. J Orthop Sports Phys Ther 2021;51(5):204-206. Epub 15 Mar 2021. doi:10.2519/jospt.2021.10340.

Digital pain drawings are a useful and reliable tool for assessing patients with temporomandibular disorders.

BACKGROUND: Temporomandibular disorders (TMD) are characterised by complex symptomatology and their assessment can be enhanced using pain drawings (PD). OBJECTIVES: To evaluate the location and extent of pain in people TMD using digital PD, and to explore their association with clinical features. Reliability of pain extent and pain location using PD was also assessed. METHODS: Forty volunteers with TMD completed two consecutive digital PDs. Clinical features were captured from self-reported questionnaire. Additionally, secondary hyperalgesia was measured using the pressure pain threshold (PPT). The correlation between pain extent and clinical features was investigated using Spearman rank correlation coefficients. Reliability of pain extent was evaluated using intraclass correlation coefficient (ICC) and Bland-Altman plots. The Jaccard index was computed to assess the reliability of pain location. RESULTS: Analysis of the PDs indicated that people with TMD commonly experience pain in other body regions including the neck, the shoulder and the low back. Except for PPT and pain catastrophising, all other clinical features were significantly correlated with pain extent. The ICCs of pain extent for all body charts were very high (ICCs 95% CI from 0.73 to 0.96), and Bland-Altman plots showed mean biases close to zero with narrow limits of agreement. The reliability of pain location was also supported by Jaccard index mean scores above 0.68. CONCLUSIONS: People with TMD showed widespread pain, and pain extent was associated with pain intensity, neck and headache-related disability, depression, anxiety, hyperventilation and central sensitivity. The reliability of measuring pain extent and pain location was confirmed.

Effects of Mulligan Mobilization with Movement in Subacute Lateral Ankle Sprains: A Pragmatic Randomized Trial.

Objective: In a pragmatic and randomized clinical trial, patients with lateral ankle sprains were assessed, under blinded conditions, for their responsiveness and improvements during Mulligan mobilization-with-movement (MWM) therapy. Methods: Overall, 51 participants with subacute lateral ankle sprains (Grade I-II) were recruited. Following an MWM screening procedure, responders were randomized to either an intervention group (MWM) or a sham group. The MWM group received inferior tibiofibular, talocrural, or cubometatarsal MWM. The treatment or sham was administered upon three sessions, each 4 days apart. Changes from baseline were measured and compared between the sessions for dorsiflexion range of motion, pain, stiffness perception, and the Y-balance test. Results: In total, 43 participants were considered responders to MWM. Using a two-way repeated-measure ANOVA, a statistical and clinically meaningful improvement in dorsiflexion range of motion was revealed in the MWM group (p = 0.004, 1rst = +1.762 cm; 3rd = +2.714 cm), whereas no improvement following the first session occurred in the sham group (p = 0.454, 1rsttrial = +1.091 cm; 3rdtrial = +1.409 cm). Pain and stiffness significantly improved, yet below the clinically meaningful level. The MWM group demonstrated a significant improvement after three sessions for the Y-balance test (p = 0.001, +8.857 cm). Conclusion: More than 80% of participants with subacute lateral ankle sprains responded well to the MWM approach. Three sessions of pragmatically determined MWM provided a significant and clinically meaningful benefit in dorsiflexion range of motion and Y-balance test performance compared to a sham treatment.

Attitudes and beliefs on low back pain in physical therapy education: A cross-sectional study.

BACKGROUND: Prescription behavior in low back pain (LBP) differs between physical therapists with a biomedical versus a biopsychosocial belief, despite the presence of clinical guidelines. OBJECTIVE: To examine (1) the beliefs of physical therapy students and their adherence to clinical LBP guidelines in Belgium and the Netherlands; (2) whether the beliefs and attitudes of physical therapy students change during education; (3) whether beliefs are related to guideline adherence; (4) whether beliefs and attitudes differ with or without a personal history of LBP. METHODS: A cross-sectional design included students in the 2nd and 4th year of physical therapy education in 6 Belgian and 2 Dutch institutions. To quantify beliefs, the Pain Attitudes and Beliefs Scale, the Health Care Providers' Pain and Impairment Relationship Scale, and a clinical case vignette were used. RESULTS: In total, 1624 students participated. (1) Only 47% of physical therapy students provide clinical guidelines' consistent recommendations for activity and 16% for work. (2) 2nd year students score higher on the biomedical subscales and lower on the psychosocial subscale. 4th year students make more guideline consistent recommendations about work and activity. (3) Students with a more biopsychosocial belief give more guideline adherent recommendations. (4) Personal experience with LBP is not associated with different beliefs or attitudes. CONCLUSIONS: A positive shift occurs from a merely biomedical model towards a more biopsychosocial model from the 2nd to the 4th year of physical therapy education. However, guideline adherence concerning activity and work recommendations remains low.

Establishing Central Sensitization-Related Symptom Severity Subgroups: A Multicountry Study Using the Central Sensitization Inventory.

OBJECTIVES: The goal of this study was to identify central sensitization-related symptom severity subgroups in a large multicountry sample composed of patients with chronic pain and pain-free individuals using the Central Sensitization Inventory (CSI). METHODS: A large, pooled international (N = 8 countries) sample of chronic pain patients plus healthy subjects (total N = 2,620) was randomly divided into two subsamples for cross-validation purposes. First, a hierarchical cluster analysis (HCA) was performed using CSI item-level data as clustering variables (test sample; N = 1,312). Second, a latent profile analysis (LPA) was conducted to confirm the optimal number of CSI clusters (validation sample; N = 1,308). Finally, to promote implementation in real-world clinical practice, we built a free online Central Sensitization Inventory Symptom Severity Calculator. RESULTS: In both HCA (N = 1,219 valid cases) and LPA (N = 1,245 valid cases) analyses, a three-cluster and three-profile solution, respectively, emerged as the most statistically optimal and clinically meaningful. Clusters were labeled as follows: (i) Low Level of CS-Related Symptom Severity, (ii) Medium Level of CS-Related Symptom Severity, and (iii) High Level of CS-Related Symptom Severity. CONCLUSIONS: Our results indicated that a three-cluster solution clearly captured the heterogeneity of the CSI data. The calculator might provide an efficient way of classifying subjects into the cluster groups. Future studies should analyze the extent to which the CSI cluster classification correlates with other patient-reported and objective signs and symptoms of CS in patients with chronic pain, their associations with clinical outcomes, health-related costs, biomarkers, (etc.), and responsiveness to treatment.

Within- and between-session reliability of secondary hyperalgesia induced by electrical high-frequency stimulation.

BACKGROUND: An increasing number of studies are focusing on secondary hyperalgesia to better understand central sensitization, as this phenomenon may play an important role in persistent pain. Recent studies have shown that, compared to the classical high-frequency stimulation protocol (HFS) at 100 Hz, a protocol using 42 Hz stimulation induces a more intense and a larger area of secondary hyperalgesia (SH). OBJECTIVES: The aim of this study was to investigate the within- and between-session reliability of SH induced by this optimized HFS protocol. METHODS: Thirty-two healthy subjects received HFS to their volar forearm in two sessions, separated by at least 2 weeks. SH was assessed by measuring the area size of increased sensitivity to pinprick stimuli after applying HFS, the sensitivity to pinprick stimuli after applying HFS and the change in pinprick sensitivity after versus before HFS. Assessments were made before HFS, and 30, 35 and 40 min after HFS. Relative and absolute reliability were analysed using intraclass correlation coefficients (ICCs), coefficients of variation (CVs), standard error of means (SEMs) and the minimum detectable changes (MDCs). RESULTS: The area of SH showed good to excellent within-session and between-session relative reliability (ICCs > 0.80), except for the change in pinprick sensitivity, which showed close to poor between-session relative reliability (ICC = 0.53). Furthermore, measures of absolute reliability generally demonstrated large between-subject variability and significant fluctuations across repeated measurements. CONCLUSIONS: HFS-induced hyperalgesia is suitable to discriminate or compare individuals but it may not be sensitive to changes due to an intervention. SIGNIFICANCE: It is crucial to evaluate central sensitization adequately in humans. This study formally establishes the reliability of secondary hyperalgesia induced by electrical high-frequency stimulation. The results of this study will improve future studies investigating secondary hyperalgesia in humans.

International consensus on the most useful assessments used by physical therapists to evaluate patients with temporomandibular disorders: A Delphi study.

OBJECTIVE: To identify assessment tools used to evaluate patients with temporomandibular disorders (TMD) considered to be clinically most useful by a panel of international experts in TMD physical therapy (PT). METHODS: A Delphi survey method administered to a panel of international experts in TMD PT was conducted over three rounds from October 2017 to June 2018. The initial contact was made by email. Participation was voluntary. An e-survey, according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES), was posted using SurveyMonkey for each round. Percentages of responses were analysed for each question from each round of the Delphi survey administrations. RESULTS: Twenty-three experts (completion rate: 23/25) completed all three rounds of the survey for three clinical test categories: 1) questionnaires, 2) pain screening tools and 3) physical examination tests. The following was the consensus-based decision regarding the identification of the clinically most useful assessments. (1) Four of 9 questionnaires were identified: Jaw Functional Limitation (JFL-8), Mandibular Function Impairment Questionnaire (MFIQ), Tampa Scale for Kinesiophobia for Temporomandibular disorders (TSK/TMD) and the neck disability index (NDI). (2) Three of 8 identified pain screening tests: visual analog scale (VAS), numeric pain rating scale (NRS) and pain during mandibular movements. (3) Eight of 18 identified physical examination tests: physiological temporomandibular joint (TMJ) movements, trigger point (TrP) palpation of the masticatory muscles, TrP palpation away from the masticatory system, accessory movements, articular palpation, noise detection during movement, manual screening of the cervical spine and the Neck Flexor Muscle Endurance Test. CONCLUSION: After three rounds in this Delphi survey, the results of the most used assessment tools by TMD PT experts were established. They proved to be founded on test construct, test psychometric properties (reliability/validity) and expert preference for test clusters. A concordance with the screening tools of the diagnostic criteria of TMD consortium was noted. Findings may be used to guide policymaking purposes and future diagnostic research.