Pain-Related Fear, Pain Intensity and Function in Individuals With Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis

"My Pain Is Unbearable…I Cannot Recognize Myself!" Emotions, Cognitions, and Behaviors of People Living With Musculoskeletal Disorders: An Umbrella Review

OBJECTIVE

To summarize (1) the emotions, cognitions, and behaviors of people who are living with musculoskeletal disorders related to symptoms and (2) the interactions of emotions, cognitions, and behaviors with the person's environment (family, social, and work roles).

DESIGN

An umbrella review of qualitative research syntheses and meta-summaries (metasynthesis, meta-ethnographies, meta-aggregation, meta-summary).

LITERATURE SEARCH

We searched CINAHL, EMBASE, PsycARTICLES, PsycEXTRA, PsycINFO, PubMed, and PubPsych from database inception to January 2021. We also searched gray literature via Open Grey and Google Scholar.

STUDY SELECTION CRITERIA

We included qualitative evidence syntheses evaluating adults with musculoskeletal disorders, based on the multidimensional diagnostic criteria for acute and chronic pain. Emotions, cognitions, and behaviors were the phenomenon of interest.

DATA SYNTHESIS

We developed 3 categories of themes ([1] emotions, [2] cognitions, and [3] behaviors) for each objective. We selected the 3 most common emotions, cognitions, and behaviors that appear as themes in our narrative synthesis.

RESULTS

We included 20 qualitative evidence syntheses that retrieved 284 original qualitative studies. Despair, distress, and fear were the main emotions reported by people living with musculoskeletal disorders. The alterations of the self and how people described their symptoms, what caused them, and how the symptoms impacted their lives were the most common cognitions. Cognitive strategies (ie, acceptance) and perceptions about social support emerged. People often used passive behaviors (eg, social isolation or hiding symptoms) to cope with the challenges that arose related to musculoskeletal symptoms. However, some people actively faced their symptoms, planning their activities or practicing them despite their symptoms.

CONCLUSION

Clinicians who support people living with musculoskeletal disorders should consider (1) assessing other emotions than pain-related fear (eg, despair and distress), (2) observing their cognitive responses (ie, acceptance), and (3) evaluating what type of behaviors people use (eg, active or passive). J Orthop Sports Phys Ther 2022;52(5):243-261. doi:10.2519/jospt.2022.10707.

The detrimental impact of temporomandibular disorders (mis)beliefs and possible strategies to overcome

AIM

This topical review presents common patients' misbeliefs about temporomandibular disorders (TMD) and discusses their possible impact on the diagnosis, treatment and prognosis. We also discussed the possible influence of the beliefs and behaviors of health care providers on the beliefs of patients with TMD and present possible strategies to overcome the negative impacts of such misbeliefs.

METHODS

This topical review was based on a non-systematic search for studies about the beliefs of patients and professionals about TMD in PubMed and Embase.

RESULTS

Patients' beliefs can negatively impact the diagnosis, treatment, and prognosis of TMD. These beliefs can be modulated by several factors such as culture, psychosocial aspects, gender, level of knowledge, and previous experiences. Moreover, primary health care professionals, including dentists, may lack sufficient experience and skills regarding TMD diagnosis and treatment. Misbeliefs of the health care professionals can be based on outdated evidence that is not supported by rigorous methodological investigations. Education and dissemination of knowledge to patients and the general population are effective for prevention, promotion of health and disruption of the cycle of misinformation and dissemination of misbeliefs.

CONCLUSION

The lack of basic information about TMD and the dissemination of mistaken and outdated concepts may delay the diagnosis, hinder the treatment, and consequently increase the risk of worsening the condition. Education is key to overcome TMD misbeliefs.

Identifying Motor Control Strategies and Their Role in Low Back Pain: A Cross-Disciplinary Approach Bridging Neurosciences With Movement Biomechanics

Persistent low back pain (LBP) is a major health issue, and its treatment remains challenging due to a lack of pathophysiological understanding. A better understanding of LBP pathophysiology has been recognized as a research priority, however research on contributing mechanisms to LBP is often limited by siloed research within different disciplines. Novel cross-disciplinary approaches are necessary to fill important knowledge gaps in LBP research. This becomes particularly apparent when considering new theories about a potential role of changes in movement behavior (motor control) in the development and persistence of LBP. First evidence points toward the existence of different motor control strategy phenotypes, which are suggested to have pain-provoking effects in some individuals driven by interactions between neuroplastic, psychological and biomechanical factors. Yet, these phenotypes and their role in LBP need further validation, which can be systematically tested using an appropriate cross-disciplinary approach. Therefore, we propose a novel approach, connecting methods from neuroscience and biomechanics research including state-of-the-art optical motion capture, musculoskeletal modeling, functional magnetic resonance imaging and assessments of psychological factors. Ultimately, this cross-disciplinary approach might lead to the identification of different motor control strategy phenotypes with the potential to translate into clinical research for better treatment options.

The Influence of Exercise Intensity on Psychosocial Outcomes in Musculoskeletal Disorders: A Systematic Review

CONTEXT

Psychosocial parameters play an important role in the onset and persistence of chronic musculoskeletal disorders (CMSDs). Exercise therapy is a valuable therapeutic modality as part of CMSD rehabilitation. Hereby, exercise intensity is an important factor regarding changes in pain and disability in multiple CMSDs. However, the impact of exercise intensity on psychosocial outcomes remains poorly explored.

OBJECTIVE

To identify the effects of different modes of exercise intensity on psychosocial outcomes in persons with CMSDs.

DATA SOURCES

A systematic search was conducted up to November 2020 using the following databases: PubMed/MEDline, PEDro, Cochrane Library, and Web of Science.

STUDY SELECTION

Studies reporting exercise therapy in CMSDs with a predefined display of exercise intensity and an evaluation of at least 1 psychosocial outcome were included.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 2a.

DATA EXTRACTION

Data regarding demographics, exercise intensity, and psychosocial outcomes were included in a descriptive analysis. Methodological quality was assessed using the PEDro scale and Critical Appraisal Skills Programme (CASP) checklist.

RESULTS

A total of 22 studies, involving 985 participants (with fibromyalgia, chronic low back pain, knee osteoarthritis, psoriatic arthritis, and axial spondyloarthritis) were included (mean PEDro score = 5.77/10). The most common psychosocial outcomes were quality of life (QoL) (n = 15), depression (n = 10), and anxiety (n = 9). QoL improved at any exercise intensity in persons with fibromyalgia. However, persons with fibromyalgia benefit more from exercising at low to moderate intensity regarding anxiety and depression. In contrast, persons with chronic low back pain benefit more from exercising at a higher intensity regarding QoL, anxiety, and depression. Other CMSDs only showed limited or conflicting results regarding the value of certain exercise intensities.

CONCLUSION

Psychosocial outcomes are influenced by the intensity of exercise therapy in fibromyalgia and chronic low back pain, but effects differ across other CMSDs. Future research is necessary to determine the exercise intensity that yields optimal exercise therapy outcomes in specific CMSDs.

Individual Patterns and Temporal Trajectories of Changes in Fear and Pain during Exposure In Vivo: A Multiple Single-Case Experimental Design in Patients with Chronic Pain

Exposure in vivo (EXP) is an effective treatment to reduce pain-related fear and disability in chronic pain populations. Yet, it remains unclear how reductions in fear and pain relate to each other. This single-case experimental design study attempted to identify patterns in the individual responses to EXP and to unravel temporal trajectories of fear and pain. Daily diaries were completed before, during and after EXP. Multilevel modelling analyses were performed to evaluate the overall effect. Temporal effects were scrutinized by individual regression analyses and determination of the time to reach a minimal clinically important difference. Furthermore, individual graphs were visually inspected for potential patterns. Twenty patients with chronic low back pain and complex regional pain syndrome type I were included. On a group level, both fear and pain were reduced following EXP. Individually, fear was significantly reduced in 65% of the patients, while pain in only 20%. A decrease in fear was seen mostly in the first weeks, while pain levels reduced later or remained unchanged. Daily measurements provided rich data on temporal trajectories of reductions in fear and pain. Overall, reductions in fear preceded pain relief and seemed to be essential to achieve pain reductions.

Behavioral Health, Telemedicine, and Opportunities for Improving Access

PURPOSE OF REVIEW

The purpose of this review is to summarize advances in behavioral treatments for pain and headache disorders, as well as recent innovations in telemedicine for behavioral treatments.

RECENT FINDINGS

Research for behavioral treatments continues to support their use as part of a multidisciplinary approach to comprehensive management for pain and headache conditions. Behavioral treatments incorporate both behavioral change and cognitive interventions and have been shown to improve outcomes beyond that of medical management alone. The onset of the COVID-19 public health emergency necessitated the rapid uptake of nontraditional modalities for behavioral treatments, particularly telemedicine. Telemedicine has long been considered the answer to several barriers to accessing behavioral treatments, and as a result of COVID-19 significant progress has been made evaluating a variety of telemedicine modalities including synchronous, asynchronous, and mobile health applications. Researchers are encouraged to continue investigating how best to leverage these modalities to improve access to behavioral treatments and to continue evaluating the efficacy of telemedicine compared to traditional in-person care. Comprehensive pain and headache management should include behavioral treatments to address a variety of behavior change and cognitive targets. Policy changes and advances in telemedicine for behavioral treatments provide the opportunity to address historical barriers limiting access.

Health-Related Outcomes 3-15 Years Following Ankle Sprain Injury in Youth Sport: What Does the Future Hold?

BACKGROUND

This study examined the association between youth sport-related ankle sprain injury and health-related outcomes, 3-15 years postinjury.

METHODS

A historical cohort study in which uninjured controls were cluster-matched with injured cases. The primary outcome was self-reported Foot and Ankle Outcome Score (FAOS). Secondary outcomes included measures of adiposity, validated questionnaires for physical activity, athletic identity, fear of pain, and tests of strength, balance, and function.

RESULTS

We recruited 86 participants (median age of 23 years; 77% female); 50 with a time-loss ankle sprain, median of 8 years postinjury, and 36 uninjured controls cluster-matched by sex and sport. Based on mixed effects multivariable regression models, previously injured participants demonstrated poorer outcomes than controls on all 5 FAOS subscales regardless of sex and time since injury, with the largest differences observed in symptoms (-20.9, 99% CI: -29.5 to -12.3) and ankle-related quality of life (-25.3, 99% CI: -34.7 to -15.9) subscales. Injured participants also had poorer unipedal dynamic balance (-1.9, 99% CI: 3.5 to -0.2) and greater fear of pain (7.2, 99% CI: 0.9-13.4) compared with controls. No statistically significant differences were found for other secondary outcomes.

CONCLUSION

At 3-15 years following time-loss ankle sprain injury in youth sport, previously injured participants had more pain and symptoms, poorer self-reported function, ankle-related quality of life, reduced sport participation, balance, and greater fear of pain than controls. This underlines the need to promote the primary prevention of ankle sprains and secondary prevention of potential health consequences, including posttraumatic osteoarthritis.

LEVEL OF EVIDENCE

Level III, historical cohort study.

The relationship between chronic pain and psychosocial aspects in patients with haemophilic arthropathy. A cross-sectional study

BACKGROUND

Pain is a major characteristic in haemophilic arthropathy. Identifying the psychosocial variables affected by pain can help when addressing these patients.

AIM

To assess the relationship between perceived intensity of chronic pain and joint damage, kinesiophobia, catastrophism, anxiety and perceived quality of life in adult patients with haemophilic arthropathy.

METHODS

Multicentre cross-sectional descriptive study. Seventy-seven adult patients with haemophilic arthropathy were recruited. The usual and maximum pain intensity (Visual Analog Scale), joint status (Haemophilia Joint Health Score), Kinesiophobia (Tampa Scale of Kinesiophobia), catastrophism (Pain catastrophizing scale), anxiety (State-Trait Anxiety inventory) and perceived quality of life (36-Item Short Form Health Survey) were evaluated. The correlation between usual and maximum pain intensity with quantitative variables was obtained with Spearman`s correlation test. Kruskal-Wallis one-way ANOVA analysed differences in perceived pain according to the severity and type of treatment, and development of inhibitors.

RESULTS

The usual intensity of perceived pain correlated positively with catastrophism, kinesiophobia, and state and trait anxiety. The same results were obtained when analysing the maximum perception of pain. We found an inverse correlation between the physical component of perceived quality of life and usual and maximum pain intensity perceived by patients.

CONCLUSION

Psychosocial factors affect the painful experience of patients with haemophilic arthropathy. Pain intensity affects the quality of life of these patients.

Pain-related fear phenotypes are associated with function of the upper limbs in individuals with shoulder pain

OBJECTIVE

To identify and describe phenotypes related to kinesiophobia, fear-avoidance, and pain catastrophizing, and determine clinical and demographic characteristics related to each phenotype as a function of self-reported function of the upper limbs in individuals with shoulder pain.

METHODS

One hundred and seventy-seven individuals with shoulder pain participated in this study. Tampa Scale of Kinesiophobia, Fear-Avoidance Beliefs Questionnaire, Pain Catastrophizing Scale, Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH), Numerical Pain of Rating Scale, and the angular onset of pain during the elevation of the arm were measured in all participants. A cluster analysis was performed considering kinesiophobia, fear-avoidance, and pain catastrophizing, then clinical and demographic characteristics of clusters were used to model individual's chance to belong to one of the clusters as a function of DASH.

RESULTS

Two clusters were identified based on kinesiophobia, fear-avoidance, and pain catastrophizing. The cluster with worse pain-related fear profile presented (p < 0.05) higher age, worse function, and higher pain intensity. This same cluster was also associated with involvement of the dominant side (OR = 2.10, 95% CI = 1.03, 4.41) and worse function (OR = 0.96, 95% CI = 0.94, 0.98).

CONCLUSION

This study identified that individuals with worse pain-related fear profile were older, with worse function, and higher pain intensity. Worse function and involvement of the dominant side were associated with the phenotype with a worse pain-related fear condition.

Widespread Pressure Delivered by a Weighted Blanket Reduces Chronic Pain: A Randomized Controlled Trial

Pleasant sensation is an underexplored avenue for modulation of chronic pain. Deeper pressure is perceived as pleasant and calming, and can improve sleep. Although pressure can reduce acute pain, its effect on chronic pain is poorly characterized. The current remote, double-blind, randomized controlled trial tested the hypothesis that wearing a heavy weighted blanket - providing widespread pressure to the body - relative to a light weighted blanket would reduce ratings of chronic pain, mediated by improvements in anxiety and sleep. Ninety-four adults with chronic pain were randomized to wear a 15-lb. (heavy) or 5-lb. (light) weighted blanket during a brief trial and overnight for one week. Measures of anxiety and chronic pain were collected pre- and post-intervention, and ratings of pain intensity, anxiety, and sleep were collected daily. After controlling for expectations and trait anxiety, the heavy weighted blanket produced significantly greater reductions in broad perceptions of chronic pain than the light weighted blanket (Cohen's f = .19, CI [-1.97, -.91]). This effect was stronger in individuals with high trait anxiety (P = .02). However, weighted blankets did not alter pain intensity ratings. Pain reductions were not mediated by anxiety or sleep. Given that the heavy weighted blanket was associated with greater modulation of affective versus sensory aspects of chronic pain, we propose that the observed reductions are due to interoceptive and social/affective effects of deeper pressure. Overall, we demonstrate that widespread pressure from a weighted blanket can reduce the severity of chronic pain, offering an accessible, home-based tool for chronic pain. The study purpose, targeted condition, study design, and primary and secondary outcomes were pre-registered in ClinicalTrials.gov (NCT04447885: "Weighted Blankets and Chronic Pain"). Perspective: This randomized-controlled trial showed that a 15-lb weighted blanket produced significantly greater reductions in broad perceptions of chronic pain relative to a 5-lb weighted blanket, particularly in highly anxious individuals. These findings are relevant to patients and providers seeking home-based, nondrug therapies for chronic pain relief.

Low back pain

Low back pain covers a spectrum of different types of pain (eg, nociceptive, neuropathic and nociplastic, or non-specific) that frequently overlap. The elements comprising the lumbar spine (eg, soft tissue, vertebrae, zygapophyseal and sacroiliac joints, intervertebral discs, and neurovascular structures) are prone to different stressors, and each of these, alone or in combination, can contribute to low back pain. Due to numerous factors related to low back pain, and the low specificity of imaging and diagnostic injections, diagnostic methods for this condition continue to be a subject of controversy. The biopsychosocial model posits low back pain to be a dynamic interaction between social, psychological, and biological factors that can both predispose to and result from injury, and should be considered when devising interdisciplinary treatment plans. Prevention of low back pain is recognised as a pivotal challenge in high-risk populations to help tackle high health-care costs related to therapy and rehabilitation. To a large extent, therapy depends on pain classification, and usually starts with self-care and pharmacotherapy in combination with non-pharmacological methods, such as physical therapies and psychological treatments in appropriate patients. For refractory low back pain, a wide range of non-surgical (eg, epidural steroid injections and spinal cord stimulation for neuropathic pain, and radiofrequency ablation and intra-articular steroid injections for mechanical pain) and surgical (eg, decompression for neuropathic pain, disc replacement, and fusion for mechanical causes) treatment options are available in carefully selected patients. Most treatment options address only single, solitary causes and given the complex nature of low back pain, a multimodal interdisciplinary approach is necessary. Although globally recognised as an important health and socioeconomic challenge with an expected increase in prevalence, low back pain continues to have tremendous potential for improvement in both diagnostic and therapeutic aspects. Future research on low back pain should focus on improving the accuracy and objectivity of diagnostic assessments, and devising treatment algorithms that consider unique biological, psychological, and social factors. High-quality comparative-effectiveness and randomised controlled trials with longer follow-up periods that aim to establish the efficacy and cost-effectiveness of low back pain management are warranted.

Left to themselves: Time to target chronic pain in childhood rare diseases

BACKGROUND

Chronic pain is prevalent among patients with rare diseases (RDs). However, little is understood about how biopsychosocial mechanisms may be integrated in the unique set of clinical features and therapeutic challenges inherent in their pain conditions.

METHODS

This review presents examples of major categories of RDs with particular pain conditions. In addition, we provide translational evidence on clinical and scientific rationale for psychosocially- and neurodevelopmentally-informed treatment of pain in RD patients.

RESULTS

Neurobiological and functional overlap between various RD syndromes and pain states suggests amalgamation and mutual modulation of the respective conditions. Emotional sequelae could be construed as an emotional homologue of physical pain mediated via overlapping brain circuitry. Given their clearly defined genetic and molecular etiologies, RDs may serve as heuristic models for unraveling pathophysiological processes inherent in chronic pain.

CONCLUSIONS

Systematic evaluation of chronic pain in patients with RD contributes to sophisticated insight into both pain and their psychosocial correlates, which could transform treatment.

Physical therapist guided active intervention of chronic temporomandibular disorder presenting as ear pain: A case report

This case report describes the successful physical therapy management of a 40-year-old female who presented with left ear pain referred from the temporomandibular joint. Diagnosis was primarily based on clinical examination findings and ruling out of red flags. Guidance was given on active self-care approaches consisting of pain neuroscience education designed with individualized pain curriculum, exercise therapy, manual therapy, and breathing exercises for a period of  sixweeks. Clinically meaningful improvements were obtained in the outcome measures of Numeric Pain Rating Scale (NPRS), Patient-Specific Functional Scale (PSFS), and Global Rating of Change (GROC) scale and progress in Pain-Self Efficacy Questionnaire (PSEQ) and Tampa Scale for Kinesiophobia (TSK) scores. Positive changes were achieved with functional activities (chewing, eating, yawing, brushing teeth and physical intimacy), and the patient was pain-free on discharge, which was maintained at a six-month follow-up.

Pain by mistake: investigating a link between error-related negativity and pain avoidance behavior

ABSTRACT

Pain can be considered as a signal of "bodily error": Errors put organisms at danger and activate behavioral defensive systems. If the error is of physical nature, pain is the warning signal that motivates protective action such as avoidance behavior to safeguard our body's integrity. Interestingly, an important component of neural error processing, the error-related negativity (ERN), has been found to be related to avoidance in anxiety disorders. The present study is the first to extend these findings to pain and investigate the relationship between ERN and pain-related avoidance behavior. It was hypothesized that individuals with larger ERN amplitudes would show more pain-related avoidance behavior and would be more persistent in their avoidance despite changes in the environment. Fifty-three healthy individuals performed the Eriksen Flanker task during which their brain activity upon correct and erroneous motor responses was recorded by means of high-density electroencephalography. Avoidance behavior was assessed with an arm-reaching task using the HapticMaster robot arm. Results showed that, in contrast to our hypothesis, avoidance was not related to ERN amplitudes. Surprisingly, persons with elevated ERN amplitudes showed low levels of avoidance specifically during early acquisition trials. In contrast to earlier findings in anxiety disorders, individuals with elevated ERN amplitudes did not engage in more pain-related avoidance behavior. In fact, the opposite pattern was found at the start of acquisition: individuals with higher compared to lower ERN amplitudes were slower in learning to avoid pain. Replications and future studies on the relationship between ERN and avoidance behavior are needed.

Intervention Therapies to Reduce Pain-Related Fear in Fibromyalgia Syndrome: A Systematic Review of Randomized Clinical Trials

OBJECTIVE

This systematic review aimed to evaluate the effectiveness of different interventions at reducing pain-related fear in people with fibromyalgia and to analyze whether the included trials reported their interventions in full detail.

DESIGN

Systematic review.

SETTING

No restrictions.

METHODS

The Cochrane Library, CINAHL, EMBASE, PsycINFO, PubMed, and Scopus were searched from their inception to April 2020, along with manual searches and a gray literature search. Randomized clinical trials were included if they assessed pain-related fear constructs as the primary or secondary outcome in adults with fibromyalgia. Two reviewers independently performed the study selection, data extraction, risk-of-bias assessment, Template for Intervention Description and Replication (TIDieR) checklist assessment, and grading the quality of evidence.

RESULTS

Twelve randomized clinical trials satisfied the eligibility criteria, including 11 cohorts with a total sample of 1,441 participants. Exercise, multicomponent, and psychological interventions were more effective than controls were in reducing kinesiophobia. However, there were no differences in decreasing kinesiophobia when self-management and electrotherapy were used. There were also no differences between groups with regard to the rest of the interventions and pain-related constructs (fear-avoidance beliefs, fear of pain, and pain-related anxiety). However, a serious risk of bias and a very serious risk of imprecision were detected across the included trials. This caused the overall certainty of the judged evidence to be low and very low. Additionally, the included trials reported insufficient details to allow the full replication of their interventions.

CONCLUSIONS

This systematic review shows that there are promising interventions, such as exercise, multicomponent, and psychological therapies, that may decrease one specific type of fear in people with fibromyalgia, i.e., kinesiophobia. However, because of the low-very low certainty of the evidence found, a call for action is needed to improve the quality of randomized clinical trials, which will lead to more definitive information about the clinical efficacy of interventions in this field.

The Perceived Opportunity to Avoid Pain Paradoxically Increases Pain-Related Fear Through Increased Threat Appraisals

BACKGROUND

Although pain-related avoidance is mainly intended to reduce the accompanying anticipatory fear, avoidance behavior may paradoxically increase fear when a previous avoidance response is no longer available, suggesting that there is a bidirectional relationship between pain-related fear and avoidance.

PURPOSE

We hypothesized that avoidance can serve as a source of information that fuels irrational pain-related threat appraisals, which, in turn, increases pain-related fear.

METHODS

Participants (N = 66) were exposed to a painful heat stimulus and randomly assigned to the avoidance or control group. They were instructed to avoid the full heat intensity by pressing a stop button in the presence of a stop cue. Only avoidance group participants received a stop cue and were allowed to press the stop button, while control group participants received the same instructions but never had the opportunity to avoid the full heat intensity. In reality and unknown to participants, the intensity and duration of the heat stimulus was independent of the avoidance response. In the subsequent test phase, the avoidance response was unavailable for both groups. We measured pain-related fear, threat appraisals/harmfulness, and pain intensity.

RESULTS

In line with our expectations, pain-related fear levels were higher when the avoidance response was no longer available compared to those when the avoidance response was available. Increased threat appraisals mediated the relationship between avoidance behavior and increased pain-related fear.

CONCLUSIONS

The perceived opportunity to avoid increased pain-related fear through threat appraisals, suggesting a more complicated relationship between pain-related fear, threat appraisals, and avoidance behavior than the unidirectional relationships proposed in the fear-avoidance model. Clinical implications are discussed.

Effects of manual therapy on fear avoidance, kinesiophobia and pain catastrophizing in individuals with chronic musculoskeletal pain: Systematic review and meta-analysis

OBJECTIVE

To systematically review the effectiveness of manual therapy on fear-avoidance, kinesiophobia, and pain catastrophizing in patients with chronic musculoskeletal pain.

LITERATURE SEARCH

Databases (Medline, EMBASE, CINAHL, PEDro, CENTRAL, Web of Science, and SCOPUS) were searched from inception up to March 2020.

STUDY SELECTION CRITERIA

Two reviewers independently selected randomized controlled trials that investigated the effects of manual therapy associated or not with other interventions on fear-avoidance, kinesiophobia and pain catastrophizing in patients with chronic musculoskeletal pain.

DATA SYNTHESIS

Standardized Mean Differences (SMD) and 95% confidence interval (CI) were calculated using a random-effects inverse variance model for meta-analysis according to the outcome of interest, comparison group and follow-up period. The level of evidence was synthesized using GRADE.

RESULTS

Eleven studies were included with a total sample of 717 individuals. Manual therapy was not superior to no treatment on reducing fear-avoidance at short-term (low quality of evidence; SMD = -0.45, 95% CI -0.99 to 0.09), and intermediate-term (low quality of evidence; SMD = -0.48, 95% CI -1.0 to 0.04). Based on very-low quality of evidence, manual therapy was not better than other treatments (SMD = 0.10, 95% CI -0.56 to 0.77) on reducing fear-avoidance, kinesiophobia (SMD = -0.12, 95% CI -0.87 to 0.63) and pain catastrophizing (SMD = -0.16, 95% CI -0.48 to 0.17) at short-term.

CONCLUSION

Manual therapy may not be superior to no treatment or other treatments on improving fear-avoidance, kinesiophobia and pain catastrophizing, based on very low or low quality of evidence. More studies are necessary to strengthen the evidence of effects of manual therapy on pain-related fear outcomes.

The strength of association between psychological factors and clinical outcome in tendinopathy: A systematic review

Objective

Tendinopathy is often a disabling, and persistent musculoskeletal disorder. Psychological factors appear to play a role in the perpetuation of symptoms and influence recovery in musculoskeletal pain. To date, the impact of psychological factors on clinical outcome in tendinopathy remains unclear. Therefore, the purpose of this systematic review was to investigate the strength of association between psychological factors and clinical outcome in tendinopathy.

Methods

A systematic review of the literature and qualitative synthesis of published trials was conducted. Electronic searches of ovid MEDLINE, ovid EMBASE, PsychINFO, CINAHL and Cochrane Library was undertaken from their inception to June 2020. Eligibility criteria included RCT’s and studies of observational design incorporating measurements of psychological factors and pain, disability and physical functional outcomes in people with tendinopathy. Risk of Bias was assessed by two authors using a modified version of the Newcastle Ottawa Scale. High or low certainty evidence was examined using the GRADE criteria.

Results

Ten studies of observational design (6-cross sectional and 4 prospective studies), involving a sample of 719 participants with tendinopathy were included. Risk of bias for the included studies ranged from 12/21 to 21/21. Cross-sectional studies of low to very low level of certainty evidence revealed significant weak to moderate strength of association (r = 0.24 to 0.53) between psychological factors and clinical outcomes. Prospective baseline data of very low certainty evidence showed weak strength of association between psychological factors and clinical outcome. However, prospective studies were inconsistent in showing a predictive relationship between baseline psychological factors on long-term outcome. Cross sectional studies report similar strengths of association between psychological factors and clinical outcomes in tendinopathy to those found in other musculoskeletal conditions.

Conclusion

The overall body of the evidence after applying the GRADE criteria was low to very low certainty evidence, due to risk of bias, imprecision and indirectness found across included studies. Future, high quality longitudinal cohort studies are required to investigate the predictive value of baseline psychological factors on long-term clinical outcome.

In pursuit of 'safe' water: the burden of personal injury from water fetching in 21 low-income and middle-income countries

INTRODUCTION

Water fetching for household needs can cause injury, but documentation of the burden of harm globally has been limited. We described the frequency, characteristics and correlates of water-fetching injuries in 24 sites in 21 low-income and middle-income countries in Asia, Africa and Latin America and the Caribbean.

METHODS

In a survey of 6291 randomly selected households, respondents reported whether and how they had experienced water-fetching injuries. Responses were coded for injury type, mechanism, bodily location and physical context. We then identified correlates of injury using a multilevel, mixed-effects logistic regression model.

RESULTS

Thirteen per cent of respondents reported at least one water-fetching injury. Of 879 injuries, fractures and dislocations were the most commonly specified type (29.2%), and falls were the most commonly specified mechanism (76.4%). Where specified, 61.1% of injuries occurred to the lower limbs, and dangerous terrain (69.4%) was the most frequently reported context. Significant correlates included being female (aOR=1.50, 95% CI 1.15 to 1.96); rural (aOR=4.80, 95% CI 2.83 to 8.15) or periurban residence (aOR=2.75, 95% CI 1.64 to 4.60); higher household water insecurity scores (aOR=1.09, 95% CI 1.07 to 1.10) and reliance on surface water (aOR=1.97, 95% CI 1.21 to 3.22) or off-premise water sources that required queueing (aOR=1.72, 95% CI 1.19 to 2.49).

CONCLUSION

These data suggest that water-fetching injuries are an underappreciated and largely unmeasured public health challenge. We offer guidelines for comprehensive data collection on injuries to better capture the true burden of inadequate water access. Such data can guide the design of interventions to reduce injury risk and promote equitable water access solutions.

Cooled radiofrequency for the treatment of sacroiliac joint pain - impact on pain and psychometrics: a retrospective cohort study

Objectives Cooled radiofrequency (cRF) is an effective treatment for sacroiliac pain. In contrast to conventional radiofrequency denervation, this technique allows enlarging the area of denervation by cooling the radiofrequency probe. However, there is sparse knowledge about the impact of interventional procedures like cRF treatment of sacroiliac joint pain on psychological comorbidities. The aim of this retrospective study was to evaluate the outcome of cRF in chronic pain patients regarding the psychological outcomes anxiety, depression, sleep quality and pain related disability. Methods In this retrospective observational study 29 interventions were performed over a period of two years in 28 patients. Pre- and post-interventional pain levels, depression and anxiety scores, pain-related disability, treatment satisfaction and sleep quality were assessed by standardized and validated questionnaires. Pain medication was recorded prior to the intervention and at follow-up. Results Hospital Anxiety and Depression Scale (HADS-D) scores for depression showed a statistically significant reduction after therapy which did not remain significant after Bonferroni-Holm correction. Anxiety as measured by the HADS-A score did not show a statistically significant change. No statistically significant improvement was observed in the pain disability index. Patients reported fewer sleep disorders after treatment. Mean pain (NRS) was statistically significantly reduced 1 week post intervention and at time of follow-up. There was no clear reduction of analgesic medication. Conclusions Besides pain reduction, our data show a positive influence on sleep quality, possibly on depression, but not on anxiety and pain disability.

The Role of Positive Psychological Factors in the Association between Pain Intensity and Pain Interference in Individuals with Chronic Musculoskeletal Pain: A Cross-Sectional Study

This study aimed to test the cross-sectional mediating and moderating role that positive psychological factors play in the association between pain intensity and pain interference in individuals with chronic musculoskeletal pain. A descriptive cross-sectional study using mediation analyses was conducted, including 186 individuals with chronic musculoskeletal pain. We conducted cross-sectional mediation and moderation analyses to determine whether the positive psychological factors mediated or moderated the association between pain intensity and pain interference. Pain acceptance, pain self-efficacy, and optimism were all significantly and weakly related to pain interference when controlling for pain intensity. Pain self-efficacy and pain acceptance partially mediated the association between pain intensity and pain interference. On the other hand, the multiple mediation model did not show significant effects. The three positive psychological factors were not found to significantly moderate the association between pain intensity and pain interference. The findings suggest that in chronic musculoskeletal pain patients, the treatments may focus on [i] what they are capable of doing to manage the pain (i.e., pain self-efficacy) and [ii] being better able to accept the pain as pain waxes and wanes might be also particularly helpful. However, these results must be tested in longitudinal studies before drawing any causal conclusion.

The mechanisms of effect of a physiotherapist-delivered integrated psychological and exercise intervention for acute whiplash-associated disorders: secondary mediation analysis of a randomized controlled trial

Supplemental Digital Content is Available in the Text. Stress mediated the effect of a physiotherapist-delivered integrated intervention on multiple health outcomes and pain-related coping mediated the effect on pain self-efficacy only. Changes in depressive and posttraumatic stress symptoms were also mechanisms of effect.

Introduction:

Integrated psychological and physical treatments can improve recovery for whiplash-associated disorders (WADs). Little is known about how these interventions work.

Objective:

To examine the mechanisms by which a physiotherapist-delivered integrated intervention for acute WAD improves health outcomes.

Methods:

Secondary analysis using structural equation modelling of a randomized controlled trial comparing integrated stress inoculation training and exercise to exercise alone for acute WAD. Outcomes were disability, pain self-efficacy, pain intensity, and health-related quality of life at 12 months. The intended intervention target and primary mediator, stress was tested in parallel with pain-related coping, an additional cognitive behavioral mediator that significantly improved at posttreatment (Model 1). Stress-related constructs that commonly co-occur with stress and pain were also tested as parallel mediators: depression and pain-related coping (Model 2); and posttraumatic stress and pain-related coping (Model 3).

Results:

Reductions in stress mediated the effect of the integrated intervention on disability (β = −0.12, confidence interval [CI] = −0.21 to −0.06), pain self-efficacy (β = 0.09, CI = 0.02–0.18), pain (β = −0.12, CI = −0.21 to −0.06), and health-related quality of life (β = 0.11, CI = 0.04–0.21). There was an additional path to pain self-efficacy through pain-related coping (β = 0.06, CI = 0.01–0.12). Similar patterns were found in Models 2 and 3.

Conclusions:

Improvements in stress and related constructs of depression and posttraumatic stress, and pain-related coping were causal mechanisms of effect in a physiotherapist-delivered integrated intervention. As integrated interventions are growing in popularity, it is important to further personalize interventions for improved benefit.

Which Psychological Factors Are Involved in the Onset and/or Persistence of Musculoskeletal Pain? An Umbrella Review of Systematic Reviews and Meta-Analyses of Prospective Cohort Studies

OBJECTIVE

The objective of this study was to summarize the current status of knowledge about the longitudinal association between vulnerability or protective psychological factors and the onset and/or persistence of musculoskeletal (MSK) pain.

METHODS

PubMed, CINAHL, PsycINFO, PubPsych, Scopus, Web of Science, gray literature, and manual screening of references were searched from inception to June 15, 2019. Systematic reviews with or without meta-analysis that explored the longitudinal association between psychological factors and the onset and/or persistence of MSK pain were identified. The AMSTAR-2 tool was used to assess the risk of bias.

RESULTS

Fifty-nine systematic reviews that included 286 original research studies were included, with a total of 249,657 participants (127,370 with MSK pain and 122,287 without MSK pain at baseline). Overall, our results found that exposure to many psychological vulnerability factors such as depression, anxiety, psychological distress, and fear, among others, may increase the risk of the onset and persistence of MSK pain across time. In addition, our results also showed that a range of psychological factors considered to be "protective" such as self-efficacy beliefs, better mental health, active coping strategies, or favorable expectations of recovery may reduce the risk of the onset and persistence of MSK pain. However, all these systematic reviews were evaluated to have critically low confidence based on the AMSTAR-2 tool, indicating that findings from these reviews may be informative, but should be interpreted with caution.

DISCUSSION

The large number of methodological flaws found across reviews gives rise to a call to action to develop high-quality systematic reviews in this field.

Behavioral Conceptualization and Treatment of Chronic Pain

Pain is considered a hardwired signal of bodily disturbance belonging to a basic motivational system that urges the individual to act and to restore the body's integrity, rather than just a sensory and emotional experience. Given its eminent survival value, pain is a strong motivator for learning. Response to repeated pain increases when harm risks are high (sensitization) and decreases in the absence of such risks (habituation). Discovering relations between pain and other events provides the possibility to predict (Pavlovian conditioning) and control (operant conditioning) harmful events. Avoidance is adaptive in the short term but paradoxically may have detrimental long-term effects. Pain and pain-related responses compete with other demands in the environment. Exposure-based treatments share the aim of facilitating or restoring the pursuit of individual valued life goals in the face of persistent pain, and further improvements in pain treatment may require a paradigm shift toward more personalized approaches.

Identifying pain perceptual biases related to fear of pain and threat in a pain-free sample

BACKGROUND

The association between fear of pain (FOP) and pain intensity has remained unclear. This study aimed to examine whether highly pain-fearful participants showed pain perceptual biases to general painful stimulus or to specific threatening painful stimulus.

METHODS

Fifty-nine undergraduates were recruited into low (n = 30) and high (n = 29) FOP groups and completed a threatening pain perception task with two tasks. Task 1 assessed pain perceptual biases by calculating the percentage of near-threshold pain stimulus judged as painful and assessing the average pain intensity ratings to those painful stimuli. Task 2 assessed pain perceptual biases by measuring pain ratings to each single threshold (low intensity) and twice-threshold (high intensity) pain stimulus.

RESULTS

Results from task 1 indicated that higher FOP levels were associated with higher pain sensitivity when pain was appraised as a threat, reflected as high FOP group reporting higher pain intensity to those stimuli judged as painful in high threat condition than in low threat condition. Consistently, results from task 2 observed that when noxious stimulus intensity increased to threshold pain and twice threshold pain levels, high FOP group also generally reported higher pain intensity in high threat condition than in low threat condition. However, for both tasks, no such threat level differences were observed in low FOP group.

CONCLUSIONS

The current research emphasized that participants with higher FOP level showed pain perceptual biases to specific threatening painful stimulus. Threat appraisal of pain played a key role in the positive association between pain-related fear and pain perceptual biases.

SIGNIFICANCE

The findings highlight the modulatory influence of threat appraisal of pain in the positive association between pain-related fear and pain perceptual biases.

Action observation as a treatment option for fear avoidance behavior in chronic spinal pain

Psychological factors play an essential role in the maintenance of various chronic pain states, with fear avoidance beliefs contributing to significant functional limitation and disability in chronic spinal pain. Fear avoidance behaviors are typically managed with cognitive-behavioral interventions such as graded exposure to feared movements and graded activity programs. However, attempts to make patients with high pain-related fear perform painful actions using graded exposure therapy can be very challenging. These fear avoidance beliefs in individuals with pain are usually acquired through previous pain experiences, observation, and threating verbal input from others that movement is harmful to the spinal structures. Observational learning of fear has been recently demonstrated in several experimental studies, where participants acquired fear of pain after observing the distressed painful expressions of the volunteers performing a painful cold pressor task. The primary purpose of this paper is to propose action observation, a cognitive rehabilitation technique, as one of the treatment options for reducing fear avoidance behavior in chronic spinal pain. Action observation involves the visualization of others performing a movement or an action to influence motor behavior positively and is mainly used in stroke rehabilitation. The paper hypothesizes that the pain-related fear of movement may be reduced through observation of others performing threatening movements successfully without displaying pain or discomfort. Action observation of others successfully executing a strenuous task may break the preexisting cognitive association between movement and pain among patients with high pain-related fear. Other possible mechanisms through which observation may influence pain-related fear could be the activation of mirror neuron systems and subsequent modulation of nociceptive information through the interconnections between the amygdala (one of the brain centers for fear), descending pain modulatory system and higher cortical centers. Few initial studies that investigated the effects of action observation on other outcomes of pain, such as pain severity are described to review the hypothesis. Considering the influence of observational learning on pain-related fear, action observation may be explored as potential adjunctive treatment to reduce fear avoidance behavior in chronic spinal pain.