Convergent Validity of the Central Sensitization Inventory in Chronic Whiplash-Associated Disorders; Associations with Quantitative Sensory Testing, Pain Intensity, Fatigue, and Psychosocial Factors.

OBJECTIVE: Central sensitization is present in different pain conditions, including chronic whiplash-associated disorders. In the absence of a gold standard method of assessment to determine the presence of central sensitization, quantitative sensory testing is currently understood as an optimal proxy. Laboratory sensory testing is, however, not feasible in clinical practice, and the Central Sensitization Inventory was developed as an alternative. The aim of the current study was to evaluate the convergent validity of the Central Sensitization Inventory in chronic whiplash-associated patients by determining the association between the Central Sensitization Inventory and quantitative sensory testing, pain intensity, fatigue, and psychosocial factors. METHODS: A total of 125 chronic whiplash-associated patients completed multiple questionnaires and were subjected to pressure pain thresholds and temporal summation. RESULTS: . The Central Sensitization Inventory showed a strong association with constructs of general psychopathology, anxiety, distress, depression, and somatization in chronic whiplash-associated disorders. Moderate correlations were found with fatigue and intrusive and avoidant phenomena after a variety of traumatic events. No significant association was found between the Central Sensitization Inventory and pressure pain thresholds and temporal summation, nor between the Central Sensitization Inventory and other pain measurements. CONCLUSIONS: Overall, we found that the Central Sensitization Inventory is better in identifying the psychosocial factors related to central sensitization in chronic whiplash-associated disorders than the central nervous system adaptations. Thus, the convergent validity of the Central Sensitization Inventory appears to be only partially present in chronic whiplash-associated disorders.

Electroencephalography During Nociceptive Stimulation in Chronic Pain Patients: A Systematic Review.

BACKGROUND: With its high temporal resolution, electroencephalography (EEG), a technique that records electrical activity of cortical neuronal cells, is a potentially suitable technique to investigate human somatosensory processing. By using EEG, the processing of (nociceptive) stimuli can be investigated, along with the functionality of the nociceptive pathway. Therefore, it can be applied in chronic pain patients to objectify whether changes have occurred in nociceptive processing. Typically, so-called event-related potential (ERP) recordings are used, where EEG signals are recorded in response to specific stimuli and characterized by latency and amplitude. OBJECTIVE: To summarize whether differences in somatosensory processing occur between chronic pain patients and healthy controls, measured with ERPs, and determine whether this response is related to the subjective pain intensity. DESIGN: Systematic review. SETTING AND METHODS: PubMed, Web of Science, and Embase were consulted, and 18 case-control studies were finally included. SUBJECTS: The chronic pain patients suffered from tension-type headache, back pain, migraine, fibromyalgia, carpal tunnel syndrome, prostatitis, or complex regional pain syndrome. RESULTS: Chronic neuropathic pain patients showed increased latencies of the N2 and P2 components, along with a decreased amplitude of the N2-P2 complex, which was also obtained in FM patients with small fiber dysfunction. The latter also showed a decreased amplitude of the N2-P3 and N1-P1 complex. For the other chronic pain patients, the latencies and the amplitudes of the ERP components did not seem to differ from healthy controls. One paper indicated that the N2-P3 peak-to-peak amplitude correlates with the subjective experience of the stimulus. CONCLUSIONS: Differences in ERPs with healthy controls can mostly be found in chronic pain populations that suffer from neuropathic pain or where fiber dysfunction is present. In chronic pain populations with other etiological mechanisms, limited differences were found or agreed upon across studies.

Does Pain Neuroscience Education and Cognition-Targeted Motor Control Training Improve Cervical Motor Output? Secondary Analysis of a Randomized Clinical Trial.

BACKGROUND: In the context of interventions aimed at reducing pain, disability, and maladaptive pain cognitions in chronic neck pain, it is hypothesized that patients who have greater symptom reduction possibly also demonstrate greater improvement in cervical motor output. Therefore, the aim of this study was to examine the effect of pain neuroscience education plus cognition-targeted motor control training on cervical motor output. METHODS: Impairments in cervical motor output were measured in 64 subjects with chronic neck pain using standardized tests. Cervical muscle strength, cervical mobility, balance, and cervical neuromuscular control were derived. To assess the differences between groups in response to treatment, a random-intercept linear mixed-models analysis, applying a diagonal covariance matrix, was used. RESULTS: A significant treatment × time interaction effect was found for neuromuscular control of the deep cervical flexors, favoring the experimental treatment at 3 months' follow-up (mean group difference: 1.982; 95% confidence interval 0.779, 3.185; large effect size d = 0.82). Significant main effects of time were found for the neuromuscular capacity of scapulothoracic muscles and for cervical mobility. No significant effects were found for balance, cervical muscle strength, or endurance of cervical flexors. CONCLUSION: Pain neuroscience education combined with cognition-targeted motor control training is not more effective than biomedically focused education and exercise therapy for improving cervical motor output in people with chronic neck pain. Our findings question the relative importance of factors such as pain, disability, and maladaptive pain cognitions on cervical motor output and the need to address it in treatment.

Associations between brain morphology and motor performance in chronic neck pain: A whole-brain surface-based morphometry approach.

Changes in brain morphology are hypothesized to be an underlying process that drive the widespread pain and motor impairment in patients with chronic neck pain. However, no earlier research assessed whole-brain cortical morphology in these patients. This case-control study assesses group-differences in whole-brain morphology between female healthy controls (HC; n = 34), and female patients with chronic idiopathic neck pain (CINP; n = 37) and whiplash-associated disorders (CWAD; n = 39). Additionally, the associations between whole-brain morphology and motor performance including balance, strength, and neuromuscular control were assessed. Cortical volume, thickness, and surface area were derived from high resolution T1-weighted images. T2*-weighted images were obtained to exclude traumatic brain injury. Vertex-wise general-linear-model-analysis revealed cortical thickening in the left precuneus and increased volume in the left superior parietal gyrus of patients with CINP compared to HC, and cortical thickening of the left superior parietal gyrus compared to HC and CWAD. Patients with CWAD showed a smaller cortical volume in the right precentral and superior temporal gyrus compared to HC. ANCOVA-analysis revealed worse neuromuscular control in CWAD compared to HC and CINP, and in CINP compared to HC. Patients with CWAD showed decreased levels of strength and sway area compared to CINP and HC. Partial correlation analysis revealed significant associations between the volume of the precentral gyrus, and neuromuscular control and strength together with an association between the volume of the superior temporal gyrus and strength. Our results emphasize the role of altered gray matter alterations in women with chronic neck pain, and its association with pain and motor impairment.

Convergent Validity of the Dutch Central Sensitization Inventory: Associations with Psychophysical Pain Measures, Quality of Life, Disability, and Pain Cognitions in Patients with Chronic Spinal Pain.

OBJECTIVE: Symptoms of central sensitization (CS) have been described in patients with chronic spinal pain (CSP). Although a gold standard to diagnose CS is lacking, psychophysical pain measures are often used. The Central Sensitization Inventory (CSI) is proposed as an alternative method and indirect tool for the evaluation of CS symptomatology. The aim of the current study was to evaluate the convergent validity of the CSI by investigating the association with psychophysical pain measures and self-reported measures of current pain intensity, quality of life, disability, and catastrophizing in CSP patients. METHODS: One hundred sixteen patients with nonspecific CSP were included in the present study. Patients completed the CSI, were subjected to pressure pain thresholds (PPTs) and a conditioned pain modulation (CPM) paradigm, and completed questionnaires for current pain intensity, quality of life, pain disability, and pain catastrophizing. RESULTS: Higher CSI scores were weakly correlated with lower PPTs (-0.276 ≤ r ≤ -0.237; all P ≤ 0.01) and not with CPM efficacy (r = 0.017; P = 0.858). Higher CSI scores were moderately correlated with higher current pain intensity (r = 0.320; P < 0.001), strongly correlated with lower physical (r = -0.617; P < 0.001) and emotional (r = -0.635; P < 0.001) quality of life, and moderately correlated with higher pain disability (r = 0.472; P < 0.001) and higher pain catastrophizing (r = 0.464; P < 0.001). CONCLUSION: The CSI was weakly associated with PPTs and not with CPM efficacy in CSP patients. Moderate to strong associations were found with current pain intensity, quality of life, disability, and catastrophizing. The current results illustrate that the CSI does not reflect a direct measure of CS, yet is a representation of general distress, possible originating from CS symptoms.

Assessment of neuropathic pain following cancer treatment.

Neuropathic cancer pain (NCP) is prevalent affecting up to 58% of those with persistent pain following cancer treatment. Neuropathic pain can develop from malignancy, after neural tissue insult during surgery and/or exposure to radiation or neurotoxic agents used as part of cancer treatment regimens. Pain following cancer treatment is commonly under-treated and one barrier identified is poor recognition of pain and inadequate assessment. Recognition of the presence of NCP is important to inform pain management, which is challenging to treat and warrants the use of specific treatments to target neuropathic mechanisms. In this review, approaches for screening and classifying NCP are described. These include screening questionnaires and the application of the updated neuropathic pain grading system in a cancer context. The evidence from neuropathic pain related assessments in cancer populations is provided and highlighted under different neuropathic pain grades. Recommendations for assessment in practice are provided.

Suffering from chronic tinnitus, chronic neck pain, or both: Does it impact the presence of signs and symptoms of central sensitization?

Chronic subjective tinnitus is a prevalent symptom, which has many similarities with chronic pain. Central sensitization is considered as a possible underlying mechanism of both symptoms. Central sensitization has already been investigated in chronic pain populations but not in patients with chronic subjective tinnitus. Therefore, the main objective of this cross-sectional study was to compare signs and symptoms, indicative for central sensitization, in tinnitus patients with and without chronic idiopathic neck pain, patients with chronic idiopathic neck pain only, and healthy controls. Also, differences in psychological and lifestyle factors, possibly influencing the association between central sensitization and tinnitus, were examined as well as correlations between signs and symptoms of central sensitization, and tinnitus, pain, psychological and lifestyle factors. Differences in signs and symptoms of central sensitization were examined using the self-report Central Sensitization Inventory and QST protocol (local and distant mechanical and heat hyperalgesia, conditioned pain modulation). Tinnitus, pain, psychological and lifestyle factors were evaluated using self-report questionnaires. Symptoms of central sensitization and local mechanical hyperalgesia were significantly more present in both tinnitus groups, compared to healthy controls, but were most extensive in the group with chronic tinnitus+chronic idiopathic neck pain. Distant mechanical hyperalgesia, indicative for central sensitization, was only observed in the group with both chronic tinnitus+chronic idiopathic neck pain. This group also displayed a significantly higher psychological burden and poorer sleep than patients with chronic tinnitus only and healthy controls. Signs and symptoms of central sensitization were also shown to be associated with tinnitus impact, pain-related disability, psychological burden and sleep disturbances. This study shows preliminary evidence for the presence of central sensitization in patients with chronic tinnitus+chronic idiopathic neck pain. This could be explained by the higher perceived tinnitus impact, psychological burden and sleep problems in this group. Trial registration: This study is registered as NCT05186259 (www.clinicaltrials.gov).

Building an understanding of goal-oriented care through the experiences of people living with chronic conditions.

OBJECTIVE: To understand the concept of goal-oriented care (GOC) through the experiences of people with chronic conditions. METHOD: Interviews with people living with chronic conditions (n = 50) were analyzed in two ways. A deductive approach based on GOC attributes generated in a concept analysis on GOC: goal-elicitation, goal-setting, goal-evaluation, patients' context, and patients' needs and preferences. An inductive approach based on a thematic analysis using descriptive phenomenology. RESULTS: The phase of goal-elicitation was recognized by the participants, whereas goal-setting and goal-evaluation were experienced to a lesser extent. Regarding the underpinning attributes, mixed feelings were reported concerning the integration of the patient's context and the presence of their needs and preferences throughout the care process. The inductive analysis revealed specific attention to informing patients about their condition and treatment options and discussing goals in interprofessional collaboration. CONCLUSION: Goal-elicitation was already present and seems to be a good foundation for GOC. More attention should be given to goal-setting and goal-evaluation. PRACTICE IMPLICATIONS: Developing guidance by means of a workflow, tools, or questions might support people with chronic conditions and providers to underpin the entire care process with patients' personal goals.

Comparing tinnitus, pain, psychosocial and cognitive factors between patients with tinnitus and pain: A systematic review.

OBJECTIVE: Tinnitus is a multifactorial symptom, which shows similarities with the involved mechanisms in chronic pain. The aim of this systematic review is to provide an overview of studies comparing patients with only tinnitus to patients with pain (headache, temporomandibular joint (TMJ) pain or neck pain) with or without tinnitus, regarding tinnitus-related, pain-related, psychosocial and cognitive factors. METHODS: This systematic review was written following the PRISMA guidelines. To identify relevant articles, PubMed, Web of Science and Embase databases were searched. The risk of bias was rated using the Newcastle Ottawa scale for case-control studies. RESULTS: Ten articles were included in the qualitative analysis. The risk of bias ranged from low to moderate. Low to moderate evidence shows that patients with tinnitus experience higher mean symptom intensity, but lower psychosocial and cognitive distress, compared to patients with pain. Inconsistent results were found for tinnitus-related factors. Low to moderate evidence points to a higher severity of hyperacusis and psychosocial distress in patients with both pain and tinnitus, compared to patients with tinnitus only, as well as for positive associations between tinnitus-related factors and the presence or intensity of pain. CONCLUSION: This systematic review shows that psychosocial dysfunctions are more clearly present in patients with pain only, compared to patients with tinnitus only and the co-occurrence of tinnitus and pain increases psychosocial distress as well as hyperacusis severity. Some positive associations were identified between tinnitus-related and pain-related factors.

Reliability and discriminative validity of a screening tool for the assessment of neuromuscular control and movement control in patients with neck pain and healthy individuals.

BACKGROUND: To evaluate the reliability and discriminative validity of a proposed adapted tool for the assessment of movement control in patients with and without neck pain. METHOD: A cross-sectional study at a University hospital center involving 25 pain-free healthy controls and 25 patients suffering from neck pain. Participants were assessed by two raters for inter-rater reliability and 1 week afterwards by a same rater for intra-rater reliability. The assessment involved a test for the axioscapular (adapted scapular holding test; SHT) and craniocervical (adapted craniocervical flexion test; CCFT) region for which intra-class correlation coefficients (ICCs) were computed to define the reliability. Discriminative validity to distinguish patients from controls was assessed by cross-validated computation of sensitivity, specificity, positive and negative likelihood ratios, overall accuracy, and area under the curve. RESULTS: The proposed tool was able to reliably assess sensorimotor impairment in participants at the craniocervical region (ICCintra = [0.52-0.82]; ICCinter = [0.60-0.85]), left axioscapular region (ICCintra = [0.43-0.77]; ICCinter = 0.71-0.90), and right axioscapular region (ICCintra = [0.47-0.79]; ICCinter = [0.42-0.77]). Furthermore, the tool yielded a sensitivity of 0.86, a specificity of 0.57, and accuracy of 0.71 (based on cross-validation). CONCLUSION: The proposed tool is able to reliably evaluate patients based on their sensorimotor performance in the craniocervical and axioscapular region.Implications for rehabilitationNeck pain is related to sensorimotor impairment including neuromuscular differences and atypical sensormimotor control strategies.Clinicians should not avoid the challenging task of screening for sensorimotor impairment in patients reporting neck pain.The proposed tool supplemented with other tools might guide clinicians in the evaluation of sensorimotor impairment.

Event-Related Potentials Following Cutaneous Electrical Stimulation in Patients With Chronic Whiplash-Associated Disorders.

BACKGROUND: Whiplash injuries typically occur from a motor vehicle collision and lead to chronic whiplash-associated disorders (CWAD) in 20% to 50% of cases. Changes in neurotransmission, metabolism, and networks seem to play a role in the pathogenic mechanism of CWAD. OBJECTIVES: To further elucidate the functional brain alterations, a neurophysiological study was performed to investigate the somatosensory processing of CWAD patients by comparing the event-related potentials (ERPs) resulting from electrical nociceptive stimulation between patients suffering from CWAD and healthy controls (HC). STUDY DESIGN: Case-control study. SETTING: University Hospital in Ghent. METHODS: In this case-control study (CWAD patients/HC: 50/50), ankle and wrist electrical pain thresholds (EPT), and amplitude and latency of the event-related potentials (ERPs) resulting from 20 electrical stimuli were investigated. Correlations between the ERP characteristics, EPT, self-reported pain, disability, pain catastrophizing, and self-reported symptoms of central sensitization were investigated. RESULTS: Only the latency of the P3 component after left wrist stimulation (t = -2.283; P = 0.023) differed between both groups. In CWAD patients, the ankle EPT correlated with the amplitude of the corresponding P1 (rho s = 0.293; P = 0.044) and P3 (rho s = 0.306; P = 0.033), as well as with the amplitude of the P3 to left wrist stimulation (rho s = 0.343; P = 0.017). Self-reported symptoms of CS correlated with right wrist P3 amplitude (rho s = 0.308; P = 0.030) and latency (rho s = -0.341; P = 0.015), and the worst pain reported during the past week was correlated with left wrist P1 latency (rho s = 0.319; P = 0.029). LIMITATIONS: Although the inclusion criteria stated that CWAD patients had to report a moderate-to-severe pain-related disability, 8 of the included CWAD patients (that scored above this threshold in the inclusion questionnaire), scored below the required cutoff at baseline. CONCLUSIONS: The CWAD patients did not show signs of hypersensitivity, but their ERP characteristics were related to the intensity of the applied stimulus, self-reported symptoms of CS, and the worst pain reported during the past week.

Temporal changes in pain processing after whiplash injury, based on Quantitative Sensory Testing: A systematic review.

BACKGROUND AND OBJECTIVE: After whiplash injury, some patients develop chronic whiplash-associated disorders. The exact pathophysiology of this chronification is still unclear and more knowledge is needed regarding the different post-injury phases. Therefore, studies were searched that examined temporal changes in pain processing, measured by Quantitative Sensory Testing (QST). DATABASES AND DATA TREATMENT: This systematic review searched three electronic databases (Medline, Web of Science and Embase) for articles meeting the eligibility requirements. Risk of bias was assessed according to a modified Newcastle-Ottawa Scale. RESULTS: The 12 included studies presented moderate to good methodological quality. These studies showed altered pain processing within the first month after injury and normalization within 3 months in 59%-78% of the patients. After 3 months, recovery stagnates during the following years. Thermal and widespread mechanical hyperalgesia occur already in the acute phase, but only in eventually non-recovered patients. CONCLUSIONS: Differences in pain processing between recovering and non-recovering patients can be observed already in the acute phase. Early screening for signs of altered pain processing can identify patients with high risk for chronification. These insights in temporal changes show the importance of rehabilitation in the acute phase. Future research should target to develop a standardized (bed-site) QST protocol and collect normative data which could, in relation with self-reported pain parameters, allow clinicians to identify the risk for chronification. SIGNIFICANCE: Altered pain processing is present soon after whiplash injury, but usually recovers within 3 months. Non-recovering patients show little to no improvements in the following years. Differences between recovering and non-recovering patients can be observed by Quantitative Sensory Testing already in the acute phase. Therefore, it is considered a feasible and effective tool that can contribute to the identification of high-risk patients and the prevention of chronification.

Graph Measure Based Connectivity in Chronic Pain Patients: A Systematic Review.

BACKGROUND: Chronic pain affects 20 to 30% of the adult population worldwide and is consequently the leading cause of disability. Current developments in brain imaging technology are increasing the understanding of the pathophysiology of (chronic) pain and enabling the possibility to objectify pain. As a result, our view of the brain has evolved from a static organ to a dynamic organ that constitutes an adaptable network of linked regions. Graph theory has emerged as a framework to analyze such networks and can be applied to investigate a range of topological properties of both the functional and structural brain network or connectome, thus providing meaningful information about the organization of human brain networks. OBJECTIVES: The aim of this systematic review is to determine whether connectivity differs between chronic pain patients and healthy controls by integrating previous studies that performed graph analyses on structural or functional connectivity. A secondary aim was to determine whether graph measures correlate to clinical outcomes. STUDY DESIGN: Systematic review. METHODS: Relevant articles were searched for in PubMed and Web of Science. These were screened against certain criteria and assessed for quality. RESULTS: On a global level the transitivity, betweenness centrality, intramodular degree, and rich club organization differed between chronic pain patients and healthy controls, but the path length, modularity, degree, and (Hub Disruption Index [HDI] of) participation coefficient did not differ between both groups, along with the small-worldness. Conflicting evidence still remains about a number of global graph measures, namely the global efficiency, local efficiency, clustering coefficient, and HDI of degree. Significant correlations were found between several nodal and global graph measures on one hand, and clinical outcomes related to pain, disability, and motor control on the other hand. LIMITATIONS: No clear conclusions could be made about the majority of the nodal measures, as they were often based on single studies. CONCLUSION: Differences between chronic pain patients and healthy controls were mostly observed for the global graph measures. Future research is still needed to validate the obtained findings and to expand this knowledge to the chronic pain populations that were not discussed in the included papers.

Combining Stress Management With Pain Neuroscience Education and Exercise Therapy in People With Whiplash-Associated Disorders: A Clinical Perspective.

Individuals classified as having whiplash-associated disorder (WAD) grade II, which reflects approximately 93% of people with WAD who are commonly managed by health care professionals, exhibit both physical (eg, pain and disability) and psychological (eg, fear of movement, anxiety, posttraumatic stress) problems that, in approximately 50% of cases, persist beyond 3 months. There is still much ongoing debate regarding factors predictive of poor recovery. The strongest associations have been found for high initial pain and disability following whiplash injury. In addition, a growing body of evidence supports the clinical importance of characteristic features, such as disturbed nociceptive processing (eg, local or general hyperalgesia to cold and mechanical stimuli), inefficient cognitions and beliefs about pain/movement/recovery, and posttraumatic stress symptoms, in the development and maintenance of physical and psychological manifestations in individuals with WAD. For this reason, the field shifted away from single interventions that mainly follow a biomedical approach, such as exercise therapy and activity programs, to gold standard multimodal care (at least 2 distinct therapeutic modalities given by 1 or more health care professionals) that acknowledges the biopsychological nature of WAD. To date, there exist several multimodal care approaches to managing WAD; however, for most, the efficacy has been found to be rather limited. One may argue that the limited success of some approaches can be attributed to the fact that they focused mainly on rehabilitating the physical symptoms (eg, pain, disability) rather than also the associated cognitive (eg, catastrophizing) and psychological (eg, posttraumatic stress symptoms) symptoms of the condition, leaving much room for improvement. In this article, current and previous evidence is used to explain why and how a comprehensive and multimodal treatment for people with WAD-consisting of a combination of pain neuroscience education, cognition-targeted exercise therapy, and stress management-can be applied in clinical practice.

Culture-sensitive and standard pain neuroscience education improves pain, disability, and pain cognitions in first-generation Turkish migrants with chronic low back pain: a pilot randomized controlled trial.

Purpose: To compare the effectiveness of culture-sensitive and standard pain neuroscience education (PNE) on pain knowledge, pain intensity, disability, and pain cognitions in first-generation Turkish migrants with chronic low back pain (CLBP).Methods: Twenty-nine Turkish first-generation migrants with CLBP were randomly assigned to the culture-sensitive (n = 15) or standard PNE (n = 14) groups. Primary (pain knowledge, pain intensity, and disability) and secondary outcomes (pain beliefs, catastrophization, and fear of movement) were evaluated at baseline, immediately after the second session of PNE (week 1), and after 4 weeks.Results: There was a significant main effect of time in pain knowledge (p < .001), pain intensity (p = .03), disability (p = .002), organic and psychological pain beliefs (p = .002, p = .01), catastrophization (p = .002), and fear of movement (p = .02). However, no significant difference was found between groups in terms of all outcome measures (p > .05).Conclusions: Both PNE programs resulted in improvements in knowledge of pain, pain intensity, perceived disability, and pain cognitions. Nevertheless, the superiority of the culture-sensitive PNE approach could not be proved. Therefore, maybe migrants who are living in the host country for longer length of time do not need culturally adapted therapies due to cultural integration, while these adaptations might be essential for the recent migrants or the autochthonous population in Turkey. Further research is required to investigate the effects of culture-sensitive PNE alone or in combination with physiotherapy interventions in recent migrants or Turkish natives with CLBP.

Prescription of exercises for the treatment of chronic pain along the continuum of nociplastic pain: A systematic review with meta-analysis.

BACKGROUND AND OBJECTIVE: To compare different exercise prescriptions for patients with chronic pain along the continuum of nociplastic pain: fibromyalgia, chronic whiplash-associated disorders (CWAD), and chronic idiopathic neck pain (CINP). DATABASES AND DATA TREATMENT: Randomized controlled trials comparing different exercise parameters were included. The search was performed in the databases Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL and PEDro. Data on the parameters for the physical exercise programs for pain management were extracted for analysis. RESULTS: Fifty studies with 3,562 participants were included. For fibromyalgia, both aerobic strengthening exercises were similar and better than stretching exercises alone. Exercises could be performed in 50- to 60-min supervised sessions, 2 to 3 times a week, for 13 weeks or more. For CWAD, body awareness exercises were similar to combined exercises, and there was no difference in adding sling exercises to a strengthening exercise program. The exercises could be performed in 90-min supervised sessions, twice a week, for 10 to 16 weeks. For CINP, motor control exercises and nonspecific muscle strengthening had a similar effect. Exercises could be performed in 30- to 60-min supervised sessions, 2 to 3 times a week, for 7 to 12 weeks. CONCLUSIONS: The choice of parameters regarding exercises should emphasize global exercises in nociplastic pain conditions (such as fibromyalgia and CWAD) and specific exercises in non-nociplastic pain conditions (such as CINP) and be based on patient's preference and therapist's skills. PROSPERO REGISTRATION NUMBER: CRD42019123271. SIGNIFICANCE: The pain mechanism must be considered to optimize exercise prescription in patients with different chronic pain profiles. The main message of this article is that low to moderate intensity global exercises performed for a long period of treatment should be performed in patients with nociplastic pain predominance. Additionally, focused and intense exercises for a short period of treatment can be prescribed for patients with nociceptive pain predominance.

A contemporary neuroscience approach compared to biomedically focused education combined with symptom-contingent exercise therapy in people with chronic whiplash associated disorders: a randomized controlled trial protocol.

BACKGROUND: To address the need for a better treatment of chronic whiplash associated disorders (WAD), a contemporary neuroscience approach can be proposed. OBJECTIVE: To examine the effectiveness of a contemporary neuroscience approach, comprising pain neuroscience education, stress management, and cognition-targeted exercise therapy versus conventional physical therapy for reducing disability (primary outcome measure) and improving quality of life and reducing pain, central sensitization, and psychological problems (secondary outcome measures) in people with chronic WAD. METHODS: The study is a multi-center, two-arm randomized, controlled trial with 1-year follow-up and will be performed in two university-based and one regional hospital. People with chronic WAD (n=120) will be recruited. The experimental group will receive pain neuroscience education followed by cognition-targeted exercise therapy, and stress management. The control group will receive biomedically focused education followed by graded and active exercise therapy focusing on muscle endurance, strength, and flexibility, and ergonomic principles. The treatment will have a duration of 16 weeks. Functional status (Neck Disability Index) is the primary outcome measure. Secondary outcome measures include quality of life, pain, central sensitization, and psychological and socio-economic factors. In addition, electroencephalography will measure brain activity at rest and during a conditioned pain modulation paradigm. Assessments will take place at baseline, immediately post-treatment and at 6 and 12 months follow-up. CONCLUSIONS: This study will examine whether a contemporary neuroscience approach is superior over conventional physical therapy for improving functioning, quality of life, and reducing pain, central sensitization, and psychological problems in people with chronic WAD.

Are Reports of Pain, Disability, Quality of Life, Psychological Factors, and Central Sensitization Related to Outcomes of Quantitative Sensory Testing in Patients Suffering From Chronic Whiplash Associated Disorders?

BACKGROUND: Chronic whiplash associated disorders (CWAD) are characterized by long-lasting symptoms of neck pain occurring after an acceleration-deceleration injury. Central sensitization (CS) has been suggested as the possible underlying mechanism for these symptoms, and is characterized by changes in the central nervous system. Besides CS, psychological factors are believed to play an important role in the experience of (chronic) pain. OBJECTIVE: Investigating the relationships between self-reported pain, disability, quality of life, psychological factors, and symptoms of CS; and electrical-based quantitative sensory testing (QST) outcomes in CWAD patients. Secondly, to investigate the differences in QST between CWAD patients and pain-free controls. METHODS: Seventy-two individuals with CWAD and 55 pain-free controls underwent electrical stimuli-based QST. Detection and pain thresholds (EPT), temporal summation (TS), and conditioned pain modulation were examined. Spearman correlation and linear mixed models analyses were performed to assess, respectively, the hypothesized associations and group differences in QST. RESULTS: The Pain Catastrophizing magnification subscale correlated with the left wrist EPT (r=-0.332; P=0.004), and the Pain Anxiety Symptom Scale-20 with the left wrist (r=-0.325; P=0.005) and ankle (r=-0.330; P=0.005) EPT. TS at the ankle correlated with the CS inventory (r=0.303; P=0.010), Short Form 36 pain subscale (r=-0.325; P=0.005), and Illness Perception Questionnaire revised consequences subscale (r=0.325; P=0.005). EPTs left (P=0.011) and right wrist (P=0.023) were lower in the CWAD group, but conditioned pain modulation and TS did not differ between groups. CONCLUSION: QST outcomes relate to psychological constructs, rather than to self-reported pain intensity and distribution. Local hyperalgesia was found in individuals with CWAD, but no differences in endogenous pain facilitation nor inhibition.

Acupuncture Versus Sham Acupuncture: A Meta-Analysis on Evidence for Longer-term Effects of Acupuncture in Musculoskeletal Disorders.

EDITORIAL NOTE: The original Letter to the Editor prepared by Jones et al was based on the initial electronic version then contained several important procedural errors that resulted in erroneous conclusions as noted by Jones et al in their original Letter. Subsequently, the authors of the Letter to the Editor were notified of the corrections and they then prepared the revised Letter to the Editor published here. Jones et al did note a remaining error in Table 5 of their corrected manuscript. Based on Jones et al's observation, Lenoir et al were notified of an error on Table 5 and have addressed this in the current version of their paper published in this issue. We appreciate the input of the authors of the letter and the positive response of the author(s) of this article. Dennis C. Turk, PhD Editor-in-Chief OBJECTIVE:: Acupuncture is a common modality in the therapy of musculoskeletal disorders. The evidence for acupuncture has been examined frequently, but a clear synthesis of previous research is currently lacking. This meta-analysis aimed to summarize the evidence for nonimmediate effects of acupuncture on pain, functionality, and quality of life in patients with musculoskeletal disorders, when compared with sham acupuncture. METHODS: Search results from PubMed and Web of Science were brought together. All screening procedures were executed twice by 2 independent researchers. The pooled standardized mean difference (SMD) with its confidence interval (CI) was estimated at follow-up at <1 month, 1 to 3 months, 3 to 6 months, and >6 months. RESULTS: For pain, the SMD equalled respectively -0.47 (CI -0.76 to -0.19), -0.27 (CI -0.44 to -0.11), -0.32 (CI -0.51 to -0.13) and -0.12 (CI -0.36 to 0.11) for <1 month, 1 to 3 months, 3 to 6 months, and >6 months follow-up. For functionality, the pooled SMD equalled -0.43 (CI -0.76 to -0.10), -0.41 (CI -0.76 to -0.05), 0.07 (CI -0.22 to 0.36), and -0.13 (-0.46 to 0.19). In the area of QOL, pooled SMD of respectively 0.20 (CI 0.04 to 0.35), 0.19 (CI -0.01 to 0.39), 0.02 (CI -0.09 to 0.14) and -0.04 (CI -0.25 to 0.16) were obtained. DISCUSSION: A significant difference in therapy effect, favoring acupuncture, was found for pain at <1 month, 1 to 3 months, and 3 to 6 months, as well as on quality of life at <1 month, and on functionality at <1 month and 1 to 3 months.

Does Motor Cortex Engagement During Movement Preparation Differentially Inhibit Nociceptive Processing in Patients with Chronic Whiplash Associated Disorders, Chronic Fatigue Syndrome and Healthy Controls? An Experimental Study.

BACKGROUND: Patients with chronic fatigue syndrome (CFS) and chronic whiplash associated disorders (cWAD) present a reduced ability to activate central descending nociceptive inhibition after exercise, compared to measurements before exercise. It was hypothesised that a dysfunctional motor-induced inhibition of nociception partly explains this dysfunctional exercise-induced hypoalgesia. This study investigates if engagement of the motor system during movement preparation inhibits nociception-evoked brain responses in these patients as compared to healthy controls (HC). METHODS: The experiment used laser-evoked potentials (LEPs) during three conditions (no task, mental task, movement preparation) while recording brain activity with a 32-channel electroencephalogram in 21 patients with cWAD, 20 patients with CFS and 18 HC. Two-factor mixed design Analysis of variance were used to evaluate differences in LEP amplitudes and latencies. RESULTS: No differences in N1, N2, N2P2, and P2 LEP amplitudes were found between the HC, CFS, and cWAD groups. After nociceptive stimulation, N1, N2 (only at hand location), N2P2, and P2 LEP amplitudes significantly decreased during movement preparation compared to no task (within group differences). CONCLUSION: Movement preparation induces a similar attenuation of LEPs in patients with CFS, patients with cWAD and HC. These findings do not support reduced motor-induced nociceptive inhibition in these patients.