Upper-Limb Movement Quality before and after Surgery in Women with Breast Cancer: An Exploratory Study.

(1) Background: This study aimed to describe upper-limb (UL) movement quality parameters in women after breast cancer surgery and to explore their clinical relevance in relation to post-surgical pain and disability. (2) Methods: UL movement quality was assessed in 30 women before and 3 weeks after surgery for breast cancer. Via accelerometer data captured from a sensor located at the distal end of the forearm on the operated side, various movement quality parameters (local dynamic stability, movement predictability, movement smoothness, movement symmetry, and movement variability) were investigated while women performed a cyclic, weighted reaching task. At both test moments, the Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) questionnaire was filled out to assess UL disability and pain severity. (3) Results: No significant differences in movement quality parameters were found between the pre-surgical and post-surgical time points. No significant correlations between post-operative UL disability or pain severity and movement quality were found. (4) Conclusions: From this study sample, no apparent clinically relevant movement quality parameters could be derived for a cyclic, weighted reaching task. This suggests that the search for an easy-to-use, quantitative analysis tool for UL qualitative functioning to be used in research and clinical practice should continue.

Towards precision pain medicine for pain after cancer: the Cancer Pain Phenotyping Network multidisciplinary international guidelines for pain phenotyping using nociplastic pain criteria.

Pain after cancer remains underestimated and undertreated. Precision medicine is a recent concept that refers to the ability to classify patients into subgroups that differ in their susceptibility to, biology, or prognosis of a particular disease, or in their response to a specific treatment, and thus to tailor treatment to the individual patient characteristics. Applying this to pain after cancer, the ability to classify post-cancer pain into the three major pain phenotypes (i.e. nociceptive, neuropathic, and nociplastic pain) and tailor pain treatment accordingly, is an emerging issue. This is especially relevant because available evidence suggests that nociplastic pain is present in an important subgroup of those patients experiencing post-cancer pain. The 2021 International Association for the Study of Pain (IASP) clinical criteria and grading system for nociplastic pain account for the need to identify and correctly classify patients according to the pain phenotype early in their treatment. These criteria are an important step towards precision pain medicine with great potential for the field of clinical oncology. Within this framework, the Cancer Pain Phenotyping (CANPPHE) Network, an international and interdisciplinary group of oncology clinicians and researchers from seven countries, applied the 2021 IASP clinical criteria for nociplastic pain to the growing population of those experiencing post-cancer pain. A manual is provided to allow clinicians to differentiate between predominant nociceptive, neuropathic, or nociplastic pain after cancer. A seven-step diagnostic approach is presented and illustrated using cases to enhance understanding and encourage effective implementation of this approach in clinical practice.

Assessing Upper Limb Function in Breast Cancer Survivors Using Wearable Sensors and Machine Learning in a Free-Living Environment.

(1) Background: Being able to objectively assess upper limb (UL) dysfunction in breast cancer survivors (BCS) is an emerging issue. This study aims to determine the accuracy of a pre-trained lab-based machine learning model (MLM) to distinguish functional from non-functional arm movements in a home situation in BCS. (2) Methods: Participants performed four daily life activities while wearing two wrist accelerometers and being video recorded. To define UL functioning, video data were annotated and accelerometer data were analyzed using a counts threshold method and an MLM. Prediction accuracy, recall, sensitivity, f1-score, 'total minutes functional activity' and 'percentage functionally active' were considered. (3) Results: Despite a good MLM accuracy (0.77-0.90), recall, and specificity, the f1-score was poor. An overestimation of the 'total minutes functional activity' and 'percentage functionally active' was found by the MLM. Between the video-annotated data and the functional activity determined by the MLM, the mean differences were 0.14% and 0.10% for the left and right side, respectively. For the video-annotated data versus the counts threshold method, the mean differences were 0.27% and 0.24%, respectively. (4) Conclusions: An MLM is a better alternative than the counts threshold method for distinguishing functional from non-functional arm movements. However, the abovementioned wrist accelerometer-based assessment methods overestimate UL functional activity.

Movement Quality Parameters during Gait Assessed by a Single Accelerometer in Subjects with Osteoarthritis and Following Total Joint Arthroplasty.

This study's aim is threefold: (I) Evaluate movement quality parameters of gait in people with hip or knee osteoarthritis (OA) compared to asymptomatic controls from a single trunk-worn 3D accelerometer. (II) Evaluate the sensitivity of these parameters to capture changes at 6-weeks, 3-, 6-, and 12-months following total knee arthroplasty (TKA). (III) Investigate whether observed changes in movement quality from 6-weeks and 12-months post-TKA relates to changes in patient-reported outcome measures (PROMs). We invited 20 asymptomatic controls, 20 people with hip OA, 18 people pre- and post-TKA to our movement lap. They wore a single trunk-worn accelerometer and walked at a self-selected speed. Movement quality parameters (symmetry, complexity, smoothness, and dynamic stability) were calculated from the 3D acceleration signal. Between groups and between timepoints comparisons were made, and changes in movement quality were correlated with PROMs. We found significant differences in symmetry and stability in both OA groups. Post-TKA, most parameters reflected an initial decrease in movement quality at 6-weeks post-TKA, which mostly normalised 6-months post-TKA. Finally, improved movement quality relates to improvements in PROMs. Thus, a single accelerometer can characterise movement quality in both OA groups and post-TKA. The correlation shows the potential to monitor movement quality in a clinical setting to inform objective, data-driven personalised rehabilitation.

Can the Output of a Learned Classification Model Monitor a Person's Functional Recovery Status Post-Total Knee Arthroplasty?

Osteoarthritis is a common musculoskeletal disorder. Classification models can discriminate an osteoarthritic gait pattern from that of control subjects. However, whether the output of learned models (probability of belonging to a class) is usable for monitoring a person's functional recovery status post-total knee arthroplasty (TKA) is largely unexplored. The research question is two-fold: (I) Can a learned classification model's output be used to monitor a person's recovery status post-TKA? (II) Is the output related to patient-reported functioning? We constructed a logistic regression model based on (1) pre-operative IMU-data of level walking, ascending, and descending stairs and (2) 6-week post-operative data of walking, ascending-, and descending stairs. Trained models were deployed on subjects at three, six, and 12 months post-TKA. Patient-reported functioning was assessed by the KOOS-ADL section. We found that the model trained on 6-weeks post-TKA walking data showed a decrease in the probability of belonging to the TKA class over time, with moderate to strong correlations between the model's output and patient-reported functioning. Thus, the LR-model's output can be used as a screening tool to follow-up a person's recovery status post-TKA. Person-specific relationships between the probabilities and patient-reported functioning show that the recovery process varies, favouring individual approaches in rehabilitation.

Functional movement assessment by means of inertial sensor technology to discriminate between movement behaviour of healthy controls and persons with knee osteoarthritis.

BACKGROUND: Apart from biomechanical alterations in movement patterns, it is known that movement limitations in persons with knee osteoarthritis (PwKOA) are related to an individual's perception and belief regarding pain and disability. To gain more insights into the functional movement behaviour of PwKOA in a clinical setting, inertial sensor technology can be applied. This study first aims to evaluate the ability of inertial sensors to discriminate between healthy controls (HC) and PwKOA. Secondly, this study aims to determine the relationship between movement behaviour, pain-related factors and disability scores. METHODS: Twelve HC and 19 PwKOA were included. Five repetitions of six functional movement tasks (walking, forward lunge, sideward lunge, ascent and descent stairs, single leg squat and sit-to-stand) were simultaneously recorded by the inertial sensor system and a camera-based motion analysis system. Statistically significant differences in angular waveforms of the trunk, pelvis and lower limb joints between HC and PwKOA were determined using one-dimensional statistical parametric mapping (SPM1D). The Knee injury and Osteoarthritis Outcome Score and TAMPA scale for Kinesiophobia were used to evaluate the relationship between discriminating joint motion, pain-related factors and disability using spearman's correlation coefficients. RESULTS: PwKOA had significantly less trunk rotation, internal pelvis rotation and knee flexion ROM during walking. Additionally, the reduced knee flexion (i.e. at the end of the stance phase and swing phase) was related to increased level of perceived pain. During the sideward lunge, PwKOA had significantly less knee flexion, ankle plantarflexion and hip abduction. This decreased hip abduction (i.e. during stance) was related to higher fear of movement. Finally, PwKOA had significantly less knee flexion during the forward lunge, single leg squat and during ascent and descent stairs. No significant correlations were observed with disability. CONCLUSIONS: Inertial sensors were able to discriminate between movement characteristics of PwKOA and HC. Additionally, significant relationships were found between joint motion, perceived pain and fear of movement. Since inertial sensors can be used outside the laboratory setting, these results are promising as they indicate the ability to evaluate movement deviations. Further research is required to enable measurements of small movement deviations in clinically relevant tasks.

Assessment of Scapulothoracic, Glenohumeral, and Elbow Motion in Adhesive Capsulitis by Means of Inertial Sensor Technology: A Within-Session, Intra-Operator and Inter-Operator Reliability and Agreement Study.

Adhesive capsulitis (AC) is a glenohumeral (GH) joint condition, characterized by decreased GH joint range of motion (ROM) and compensatory ROM in the elbow and scapulothoracic (ST) joint. To evaluate AC progression in clinical settings, objective movement analysis by available systems would be valuable. This study aimed to assess within-session and intra- and inter-operator reliability/agreement of such a motion capture system. The MVN-Awinda® system from Xsens Technologies (Enschede, The Netherlands) was used to assess ST, GH, and elbow ROM during four tasks (GH external rotation, combing hair, grasping a seatbelt, placing a cup on a shelf) in 10 AC patients (mean age = 54 (± 6), 7 females), on two test occasions (accompanied by different operators on second occasion). Standard error of measurements (SEMs) were below 1.5° for ST pro-retraction and 4.6° for GH in-external rotation during GH external rotation; below 6.6° for ST tilt, 6.4° for GH flexion-extension, 7.1° for elbow flexion-extension during combing hair; below 4.4° for GH ab-adduction, 13° for GH in-external rotation, 6.8° for elbow flexion-extension during grasping the seatbelt; below 11° for all ST and GH joint rotations during placing a cup on a shelf. Therefore, to evaluate AC progression, inertial sensors systems can be applied during the execution of functional tasks.

Towards the Monitoring of Functional Status in a Free-Living Environment for People with Hip or Knee Osteoarthritis: Design and Evaluation of the JOLO Blended Care App.

(1) Background: Joint loading is an important parameter in patients with osteoarthritis (OA). However, calculating joint loading relies on the performance of an extensive biomechanical analysis, which is not possible to do in a free-living situation. We propose the concept and design of a novel blended-care app called JOLO (Joint Load) that combines free-living information on activity with lab-based measures of joint loading in order to estimate a subject's functional status. (2) Method: We used an iterative design process to evaluate the usability of the JOLO app through questionnaires. The user interfaces that resulted from the iterations are described and provide a concept for feedback on functional status. (3) Results: In total, 44 people (20 people with OA and 24 health-care providers) participated in the testing of the JOLO app. OA patients rated the latest version of the JOLO app as moderately useful. Therapists were predominantly positive; however, their intention to use JOLO was low due to technological issues. (4) Conclusion: We can conclude that JOLO is promising, but further technological improvements concerning activity recognition, the development of personalized joint loading predictions and a more comfortable means to carry the device are needed to facilitate its integration as a blended-care program.

The influence of cognitions, emotions and behavioral factors on treatment outcomes in musculoskeletal shoulder pain: a systematic review.

OBJECTIVE: To examine the predictive, moderating and mediating role of cognitive, emotional and behavioral factors on pain and disability following shoulder treatment. DATA SOURCES: Electronic databases (PubMed, Web of Science, Embase and PsycINFO) were searched until 14 January 2019. STUDY SELECTION: Studies including persons with musculoskeletal shoulder pain that describe the predictive, moderating or mediating role of baseline cognitive, emotional or behavioral factors on pain or disability following treatment were selected. RESULTS: A total of 23 articles, describing 21 studies and involving 3769 participants, were included. Three studies had a high risk of bias. There was no predictive role of baseline depression, anxiety, coping, somatization or distress on pain or disability across types of shoulder treatment. No predictive role of fear-avoidance beliefs was identified in patients receiving physiotherapy, which contrasted to the results found when surgical treatment was applied. Baseline catastrophizing was also not predictive for pain or disability in patients receiving physiotherapy. After conservative medical treatments, results on the predictive role of catastrophizing were inconclusive. Treatment expectations and baseline self-efficacy predicted pain and disability in patients receiving physiotherapy, which was not the case in patients receiving conservative medical treatment. Finally, there was a moderating role for optimism in the relationship between pain catastrophizing and disability in patients receiving physiotherapy. CONCLUSION: There is evidence that expectations of recovery and self-efficacy have a predictive role and optimism a moderating role on pain and/or disability following physiotherapy for musculoskeletal shoulder pain. After surgical treatment, fear-avoidance is a predictor of pain and disability.

Reliability and Agreement of 3D Trunk and Lower Extremity Movement Analysis by Means of Inertial Sensor Technology for Unipodal and Bipodal Tasks.

This study evaluates the reliability and agreement of the 3D range of motion (ROM) of trunk and lower limb joints, measured by inertial measurement units (MVN BIOMECH Awinda, Xsens Technologies), during a single leg squat (SLS) and sit to stand (STS) task. Furthermore, distinction was made between movement phases, to discuss the reliability and agreement for different phases of both movement tasks. Twenty healthy participants were measured on two testing days. On day one, measurements were conducted by two operators to determine the within-session and between-operator reliability and agreement. On day two, measurements were conducted by the same operator, to determine the between-session reliability and agreement. The SLS task had lower within-session reliability and agreement compared with between-session and between-operator reliability and agreement. The reliability and agreement of the hip, knee, and ankle ROM in the sagittal plane were good for both phases of the SLS task. For both phases of STS task, within-session reliability and agreement were good, and between-session and between-operator reliability and agreement were lower in all planes. As both tasks are physically demanding, differences may be explained by inconsistent movement strategies. These results show that inertial sensor systems show promise for use in further research to investigate (mal)adaptive movement strategies.

Motor Control Training for the Shoulder with Smart Garments.

Wearable technologies for posture monitoring and posture correction are emerging as a way to support and enhance physical therapy treatment, e.g., for motor control training in neurological disorders or for treating musculoskeletal disorders, such as shoulder, neck, or lower back pain. Among the various technological options for posture monitoring, wearable systems offer potential advantages regarding mobility, use in different contexts and sustained tracking in daily life. We describe the design of a smart garment named Zishi to monitor compensatory movements and evaluate its applicability for shoulder motor control training in a clinical setting. Five physiotherapists and eight patients with musculoskeletal shoulder pain participated in the study. The attitudes of patients and therapists towards the system were measured using standardized survey instruments. The results indicate that patients and their therapists consider Zishi a credible aid for rehabilitation and patients expect it will help towards their recovery. The system was perceived as highly usable and patients were motivated to train with the system. Future research efforts on the improvement of the customization of feedback location and modality, and on the evaluation of Zishi as support for motor learning in shoulder patients, should be made.

The association between pain-related psychological variables and postural control in low back pain: A systematic review and meta-analysis.

BACKGROUND: Alterations in postural control have been found in individuals with low back pain (LBP), particularly during challenging postural tasks. Moreover, higher levels of negative pain-related psychological variables are associated with increased trunk muscle activity, reduced spinal movement, and worse maximal physical performance in individuals with LBP. RESEARCH QUESTION: Are pain-related psychological variables associated with postural control during static bipedal standing tasks in individuals with LBP? METHODS: A systematic review and meta-analysis were conducted. Pubmed, Web of Science, and PsycINFO were searched until March 2023. Studies were included if they evaluated postural control during static bipedal standing in individuals with LBP by measuring center of pressure (CoP) variables, and reported at least one pain-related psychological variable. Correlation coefficients between pain-related psychological variables and CoP variables were extracted. Study quality was assessed with the "Quality In Prognosis Studies" tool (QUIPS). Random-effect models were used to calculate pooled correlation coefficients for different postural tasks. Sub-analyses were performed for positional or dynamic CoP variables. Certainty of evidence was assessed with an adjusted "Grading of Recommendations, Assessment, Development, and Evaluations" tool (GRADE). The protocol was registered on PROSPERO (CRD42021241739). RESULTS: Sixteen studies (n = 723 participants) were included. Pain-related fear (16 studies) and pain catastrophizing (three studies) were the only reported pain-related psychological variables. Both pain-related fear (-0.04 < pooled r < 0.14) and pain catastrophizing (0.28 < pooled r < 0.29) were weakly associated with CoP variables during different postural tasks. For all associations, the certainty of evidence was very low. SIGNIFICANCE: Pain-related fear and pain catastrophizing are only weakly associated with postural control during static bipedal standing in individuals with LBP, regardless of postural task difficulty. Certainty of evidence is very low thus it is conceivable that future studies accounting for current study limitations might reveal different findings.

The Role of Anxiety and Depression in Shaping the Sleep-Pain Connection in Patients with Nonspecific Chronic Spinal Pain and Comorbid Insomnia: A Cross-Sectional Analysis.

(1) Background: This exploratory study aims to explore the relationship between nonspecific chronic spinal pain (nCSP) and insomnia symptoms, by examining the interconnections, strengths, and directional dependence of the symptoms. In addition, we aim to identify the key symptoms of the nCSP-insomnia relationship and shed light on the bidirectional nature of this relationship. (2) Methods: This study is a secondary analysis of the baseline data (cross-sectional) from a randomized controlled trial, which examined the added value of Cognitive Behavioral Therapy for Insomnia (CBT-I) combined with cognition-targeted exercise therapy, conducted in collaboration with the Universiteit Gent and Vrije Universiteit Brussel (Belgium). One hundred and twenty-three nCSP patients with comorbid insomnia were recruited through the participating hospitals, advertisements, announcements in local newspapers, pharmacies, publications from support groups, and primary care. To explore the interconnections and directionality between symptoms and the strengths of the relationships, we estimated a regularized Gaussian graphical model and a directed acyclic graph. (3) Results: We found only one direct, but weak, link between sleep and pain, namely, between average pain and difficulties maintaining sleep. (4) Conclusions: Despite the lack of strong direct links between sleep and pain, pain and sleep seem to be indirectly linked via anxiety and depression symptoms, acting as presumable mediators in the network of nCSP and comorbid insomnia. Furthermore, feeling slowed down and fatigue emerged as terminal nodes, implying their role as consequences of the network.

Integration of Cognitive Behavioral Therapy for Insomnia in Best-Practice Care for Patients With Knee Osteoarthritis and Insomnia: A Randomized Controlled Trial Protocol.

OBJECTIVE: Knee osteoarthritis (KOA) is a common musculoskeletal problem worldwide and its key symptom is pain. Guidelines recommend incorporating comorbidity-specific therapies into patient-centered care. Patients diagnosed with KOA frequently have insomnia, which is associated with higher-pain severity. For this reason, this study protocol outlines the methodology of a randomized controlled trial (RCT) investigating the effectiveness of cognitive behavioral therapy for insomnia (CBTi) combined with best-practice KOA care (BPC) compared to best-practice KOA care and lifestyle education. METHODS: A 2-arm RCT in patients with KOA and insomnia is conducted, in which a total of 128 patients are randomly allocated to an intervention or control group. The experimental intervention consists of 12 sessions of physical therapist-led BPC with an additional 6 sessions of CBTi. The control intervention also receives BPC, which is supplemented with 6 general lifestyle information sessions. The primary outcome is the between-group difference in change in pain severity at 6 months after intervention. Secondary outcomes are pain-related outcomes, sleep-related outcomes, symptoms of anxiety and depression, level of physical activity and function, perceived global improvement, biomarkers of inflammation, and health-related quality of life. Assessments are conducted at baseline, immediately after intervention, and 3, 6, and 12 months after intervention. Furthermore, a cost-utility analysis for the proposed intervention will be performed alongside the RCT. IMPACT: This is the first RCT investigating the clinical and cost-effectiveness of a physical therapist-led intervention integrating CBTi into BPC in patients with KOA and insomnia. The results of this trial will add to the growing body of evidence on the effectiveness of individualized and comorbidity-specific KOA care, which can inform clinical decision-making and assist policymakers and other relevant stakeholders in optimizing the care pathway for patients with KOA.

The bidirectional relationship between sleep problems and chronic musculoskeletal pain: a systematic review with meta-analysis.

ABSTRACT: Chronic musculoskeletal pain and sleep problems/disorders exhibit a recognized bidirectional relationship; yet, systematic investigations of this claim, particularly in a prospective context, are lacking. This systematic review with meta-analysis aimed to synthesize the literature on the prospective associations between sleep problems/disorders and chronic musculoskeletal pain. A comprehensive search across 6 databases identified prospective longitudinal cohort studies in adults examining the relationship between sleep problems/disorders and chronic musculoskeletal pain. Random-effects meta-analyses, using the Hartung-Knapp adjustment for 95% confidence intervals (CIs), were conducted, and all results were presented as odds ratios (ORs). Certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations approach. Including 16 articles from 11 study populations (116,746 participants), meta-analyses indicated that sleep problems at baseline may heighten the risk of chronic musculoskeletal pain in both short term (OR 1.64, 95% CI 1.01-2.65) and long term (OR 1.39, 95% CI 1.21-1.59). The evidence for different sleep problem categories was very uncertain. Chronic musculoskeletal pain at baseline may increase the risk of short-term sleep problems (OR 1.56, 95% CI 1.02-2.38), but long-term evidence was very uncertain. The impact of only local or only widespread pain on short-term sleep problems was very uncertain, whereas widespread pain may elevate the risk of long-term sleep problems (OR 2.0, 95% CI 1.81-2.21). In conclusion, this systematic review with meta-analysis suggests that sleep problems are associated with an increased risk of chronic musculoskeletal pain, but the bidirectional nature of this relationship requires further investigation.

Personalized Multimodal Lifestyle Intervention as the Best-Evidenced Treatment for Chronic Pain: State-of-the-Art Clinical Perspective.

Chronic pain is the most prevalent disease worldwide, leading to substantial disability and socioeconomic burden. Therefore, it can be regarded as a public health disease and major challenge to scientists, clinicians and affected individuals. Behavioral lifestyle factors, such as, physical (in)activity, stress, poor sleep and an unhealthy diet are increasingly recognized as perpetuating factors for chronic pain. Yet, current management options for patients with chronic pain often do not address lifestyle factors in a personalized multimodal fashion. This state-of-the-art clinical perspective aims to address this gap by discussing how clinicians can simultaneously incorporate various lifestyle factors into a personalized multimodal lifestyle intervention for individuals with chronic pain. To do so the available evidence on (multimodal) lifestyle interventions targeting physical (in)activity, stress, sleep and nutritional factors, specifically, was reviewed and synthetized from a clinical point of view. First, advise is provided on how to design a personalized multimodal lifestyle approach for a specific patient. Subsequently, best-evidence recommendations on how to integrate physical (in)activity, stress, sleep and nutritional factors as treatment targets into a personalized multimodal lifestyle approach are outlined. Evidence supporting such a personalized multimodal lifestyle approach is growing, but further studies are needed.

Nociceptive, neuropathic, or nociplastic low back pain? The low back pain phenotyping (BACPAP) consortium's international and multidisciplinary consensus recommendations.

The potential to classify low back pain as being characterised by dominant nociceptive, neuropathic, or nociplastic mechanisms is a clinically relevant issue. Preliminary evidence suggests that these low back pain phenotypes might respond differently to treatments; however, more research must be done before making specific recommendations. Accordingly, the low back pain phenotyping (BACPAP) consortium was established as a group of 36 clinicians and researchers from 13 countries (five continents) and 29 institutions, to apply a modified Nominal Group Technique methodology to develop international and multidisciplinary consensus recommendations to provide guidance for identifying the dominant pain phenotype in patients with low back pain, and potentially adapt pain management strategies. The BACPAP consortium's recommendations are also intended to provide direction for future clinical research by building on the established clinical criteria for neuropathic and nociplastic pain. The BACPAP consortium's consensus recommendations are a necessary early step in the process to determine if personalised pain medicine based on pain phenotypes is feasible for low back pain management. Therefore, these recommendations are not ready to be implemented in clinical practice until additional evidence is generated that is specific to these low back pain phenotypes.

Understanding Discrepancies in a Person's Fear of Movement and Avoidance Behavior: A Guide for Musculoskeletal Rehabilitation Clinicians Who Support People With Chronic Musculoskeletal Pain.

BACKGROUND: Generic self-report measures do not reflect the complexity of a person's pain-related behavior. Since variations in a person's fear of movement and avoidance behavior may arise from contextual and motivational factors, a person-centered evaluation is required-addressing the cognitions, emotions, motivation, and actual behavior of the person. CLINICAL QUESTION: Most musculoskeletal rehabilitation clinicians will recognize that different people with chronic pain have very different patterns of fear and avoidance behavior. However, an important remaining question for clinicians is "How can I identify and reconcile discrepancies in fear of movement and avoidance behavior observed in the same person, and adapt my management accordingly?" KEY RESULTS: We frame a clinical case of a patient with persistent low back pain to illustrate the key pieces of information that clinicians may consider in a person-centered evaluation (ie, patient interview, self-report measures, and behavioral assessment) when working with patients to manage fear of movement and avoidance behavior. CLINICAL APPLICATION: Understanding the discrepancies in a person's fear of movement and avoidance behavior is essential for musculoskeletal rehabilitation clinicians, as they work in partnership with patients to guide tailored approaches to changing behaviors. J Orthop Sports Phys Ther 2023;53(5):1-10. Epub: 9 March 2023. doi:10.2519/jospt.2023.11420.

Are contextual factors associated with activities and participation after total hip arthroplasty? A systematic review.

OBJECTIVES: After total hip arthroplasty (THA), over 30% of individuals report activity limitations and participation restrictions. This systematic review aimed to determine the association between contextual factors and outcomes in the activity and participation domain after THA for hip osteoarthritis (OA). METHODS: This systematic review was developed according to the PRISMA guidelines for systematic reviews. PubMed, Web of Science, Embase and Scopus were searched until August 2022. Risk of bias was assessed with the Quality in Prognosis Studies tool (QUIPS). RESULTS: Twenty-nine articles were included. Eighteen had a high risk of bias, 3 had a low risk of bias, and 8 had a moderate risk of bias. Anxiety was only investigated in studies with high risk of bias but showed a consistent negative association with activities and participation after THA across multiple studies. Evidence was inconsistent regarding the associations between depression, trait anxiety, sense of coherence, big 5 personality traits, educational level, marital status, employment status, job position, expectations and social support, and the activity and participation domain. Optimism, general self-efficacy, cognitive appraisal processes, illness perception, ethnicity, and positive life events were associated with activities and participation but were only investigated in 1 study. No associations were identified across multiple studies for living or smoking status. Control beliefs, kinesiophobia, race, discharge location, level of poverty in neighbourhood, negative life events and occupational factors, were not associated with the activity and participation domain but were only investigated in 1 study. CONCLUSION: Methodological quality of the included studies was low. Anxiety was the only factor consistently associated with worse outcomes in the activity and participation domain after THA but was only investigated in studies with high risk of bias. Further research is needed to confirm relationships between other contextual factors and activities and participation after THA. REGISTRATION: PROSPERO CRD42020199070.

The development and measurement properties of the Dutch version of the fear-avoidance components scale (FACS-D) in persons with chronic musculoskeletal pain.

OBJECTIVES: The Fear-Avoidance Components Scale (FACS) is a recently developed patient-reported instrument assessing different constructs related to the fear-avoidance model of pain. The aim was to translate the original English FACS into Dutch (FACS-D) and assess its measurement properties in persons with chronic musculoskeletal pain. METHODS: The original English FACS (20 item-scale, range: 0-100) was translated in Dutch through standard forward-backward translation methodology. The FACS-D's measurement properties were evaluated in 224 persons with chronic musculoskeletal pain. Internal consistency, test-retest reliability and measurement error were assessed with the Cronbach's alpha coefficient (α), intraclass correlation coefficient (ICC), and standard error of measurement (SEM). Construct validity was assessed through inter-item correlation analyses, exploratory factor analysis, association with other fear-avoidance-related constructs, and hypothesis testing. RESULTS: Internal consistency, test-retest reliability and hypotheses testing were good (α=0.92; ICC=0.92, CI 0.80-0.96; 7/8 hypotheses confirmed). Similar to the original FACS and other translated versions, a two-factor model best fit the data. However, the item distribution differed from other versions. One factor represented "pain-related cognitions and emotions" and a second factor represented "avoidance behaviour." In contrast to the original FACS, low inter-item correlations for item 12 were found. The FACS-D was more strongly associated with fear-avoidance-related constructs of pain severity, perceived disability, feelings of injustice, and depressive/anxiety symptoms than the other fear-avoidance-related scales studied here. CONCLUSIONS: The FACS-D demonstrated good reliability and construct validity, suggesting that it may be a useful measure for Dutch-speaking healthcare providers. Two clinically relevant factors, with a different item distribution than the original FACS, were identified: one covering items on pain-related cognitions and emotions, and one covering items on avoidance behaviour. The stronger association between FACS-D and fear-avoidance related constructs suggests that the FACS-D may be more effective in evaluating the cognitive, emotional and behavioural constructs of pain-related fear-avoidance than other similar measures.