Association of psychological variables and outcome in tendinopathy: a systematic review

Depression and Somatization in Refractory Lateral Epicondylitis

Objectives

This study aims to present two major psychological factors, namely depression and somatization, which may occur with high probability in patients with refractory lateral epicondylitis (LE).

Patients and methods

This cross-sectional study included 36 patients (11 males, 25 females; mean age 42.6±8.09 years; range 26 to 60 years) diagnosed as refractory LE. Duration of symptoms was >6 months. Each patient completed the Beck Depression Inventory and the Symptom Checklist-90-Revised test evaluating psychosocial status and somatization, respectively.

Results

Depression was found in 24 (66.6%) (moderate in 15 [41.7%] and mild in 9 [25%]) and somatization was found in 28 (77.8%) patients. Depression and somatization were significantly more common in females than males (p=0.02 and p=0.04, respectively).

Conclusion

Depression and somatization may occur frequently in refractory LE patients, particularly in females. Both physical and psychological assessment tools should be incorporated into the clinical evaluation while psychological support should be included in the treatment of refractory LE.

The association of working alliance, outcome expectation, adherence and self-efficacy with clinical outcomes for Achilles tendinopathy: A feasibility cohort study (the MAP study)

INTRODUCTION

This study evaluated the feasibility of a large longitudinal cohort study utilizing an online platform to investigate the association and predictive relationship of working alliance, outcome expectations, adherence and self-efficacy with outcome in Achilles tendinopathy. The objectives were: (1) to determine the recruitment and retention rate and (2) to carry out preliminary data analysis of the selected variables and clinical outcomes.

METHODS

A multi-centred, longitudinal feasibility cohort study was used. Eligible participants were directed to a bespoke online platform hosting study information and the outcome measures in the form of an online questionnaire. Responses from the online questionnaire were collected on three occasions: at baseline, at 6 and at 12 weeks following completion of the first questionnaire. Feasibility outcomes (recruitment and retention rates) were described using descriptive statistics.

RESULTS

The website recorded a total 55 views. These 55 views resulted in 24 participants consenting to join the study. The questionnaire at baseline was started 63 times and completed on 60 separate occasions resulting in a 95% conversion rate. Retainment for completion of the questionnaire for a second time was 83.3% and for the third time was 66.6%. All questionnaires were completed fully yielding a missing data indicator of 0%.

CONCLUSIONS

Feasibility studies ask the question 'can this be done'? Based on the data from recruitment and rates and exploratory correlation analysis a future study can be done; this previously untested online platform appears feasible, but changes could be useful before proceeding to a much larger study.

General practice management of rotator cuff related shoulder pain: A reliance on ultrasound and injection guided care

OBJECTIVE

To describe general practitioner's (GP's) current management of rotator cuff related shoulder pain (RCRP) in Australia and identify if this is consistent with recommended care and best available evidence. The secondary aim was to determine if GP management of RCRP changed over time.

METHODS

Data about management of RCRP by Australian GPs was extracted from the Bettering the Evaluation of Care of Health program database over its final five years (April 2011-March 2016). Patient and GP characteristics and encounter management data were extracted. Results are reported using descriptive statistics with point estimates and 95% confidence intervals. A secondary analysis over a 16 year period (2000-2016) examined management data for RCRP in four year periods.

RESULTS

RCRP was the most common shoulder condition managed by GPs at 5.12 per 1,000 encounters; and at an estimated 732,000 times nationally in 2015-2016. Management rate was higher among male patients (5.5 per 1000 encounters c.f. 4.8 for female patients) and was highest in the 45-64 year old age group (8.6 per 1000). RCRP was most frequently managed with medications (54.7%), steroid injection (19.5%) followed by non-steroidal anti-inflammatory drugs (NSAIDs) (19.1%). Imaging was ordered for 43.4% (ultrasound 41.2% and x-ray 11.6%) of all RCRP presentations (new and returning). Over half (53.0%) of new RCRP presentations were referred for ultrasound imaging. In the 16 year period 2000-16 ultrasound imaging more than doubled from 19.1% to 41.9% of management occasions. In parallel, prescribed steroid injection increased from 9.8% to 19.7%.

CONCLUSION

The usual care provided by GPs for RCRP relies on the use of ultrasound and steroid injection. This is not consistent with recommended care and clinical guidelines that recommend these are delayed until after 6-12 weeks of NSAID medication, exercise and activity modification. There has been a significant increase in the rate of steroid injection and ultrasound imaging, which may be due in part to policy change.

Adaptation of Tendon Structure and Function in Tendinopathy With Exercise and Its Relationship to Clinical Outcome

CONTEXT

Exercise is seen as the most evidence-based treatment for managing tendinopathy and although the type of exercise used to manage tendinopathy may induce adaptation in healthy tendons, it is not clear whether these adaptations occur in tendinopathy and if so whether they are associated with improved clinical outcomes.

OBJECTIVE

The aim of the study was to synthesize available evidence for adaptation of the Achilles tendon to eccentric exercise and the relationship between adaptation (change in tendon thickness) and clinical outcomes among people with Achilles tendinopathy.

EVIDENCE ACQUISITION

The search was performed in September 2018 in several databases. Studies investigating the response (clinical outcome and imaging on ultrasound/magnetic resonance imaging) of pathological tendons (tendinopathy, tendinosis, and partial rupture) to at least 12 weeks of eccentric exercise were included. Multiple studies that investigated the same interventions and outcome were pooled and presented in effect size estimates, mean difference, and 95% confidence intervals if measurement scales were the same, or standard mean difference and 95% confidence intervals if measurements scales were different. Where data could not be pooled the studies were qualitatively synthesized based on van Tulder et al.

EVIDENCE SYNTHESIS

Eight studies met the inclusion and exclusion criteria and were included in the review. There was strong evidence that Achilles tendon thickness does not decrease in parallel with improved clinical outcomes.

CONCLUSIONS

Whether a longer time to follow-up is more important than the intervention (ie, just the time per se) for a change in tendon thickness remains unknown. Future studies should investigate whether exercise (or other treatments) can be tailored to optimize tendon adaptation and function, and whether this relates to clinical outcomes.

The efficacy of loading programmes for improving patient-reported outcomes in chronic midportion Achilles tendinopathy: A systematic review

OBJECTIVE

Achilles tendinopathy is a common type of overuse condition, with isolated eccentric loading (ECL) programmes being the principal conservative treatment of choice. However, alternative protocols, involving different contraction types, have more recently been investigated. The purpose of the present review was to examine the evidence from studies comparing two or more different types of loading programmes in relation to patient-reported outcomes for people with Achilles tendinopathy.

METHODS

A systematic review was undertaken, and the risk of bias of included papers were assessed using the Cochrane Risk of Bias tool. An electronic search of CINAHL, MEDLINE, Embase and SPORTDiscus was undertaken from their inception to May 2018. The eligibility criteria for selecting studies were randomized controlled or clinical controlled trials investigating two or more different loading programmes for chronic (>3 months) Achilles tendinopathy.

RESULTS

Seven articles were included in the review. Low-quality evidence exists that a do-as-tolerated modification of the Alfredson programme is more effective than the standardized programme at improving function in the short term. Very-low-quality evidence suggests that ECL is superior at reducing pain levels than concentric in isolation, but no more effective at improving pain or disability than concentric-eccentric programmes.

CONCLUSIONS

There is conflicting evidence regarding the superiority of ECL over other contraction types, challenging the current approach to managing Achilles tendinopathy. There is also evidence that do-as-tolerated repetition volumes are more effective at improving function in the short term compared with those recommended by the standardized Alfredson protocol.

Physical findings differ between individuals with greater trochanteric pain syndrome and healthy controls: A systematic review with meta-analysis

BACKGROUND

Understanding of the biopsychosocial characteristics of greater trochanteric pain syndrome (GTPS), a prevalent lower limb tendinopathy, is currently lacking.

OBJECTIVES

To quantify differences in participant characteristics between individuals with GTPS and healthy control participants.

DESIGN

Systematic review of original studies with meta-analyses where appropriate.

METHODS

A comprehensive electronic search was undertaken in Pubmed, EMBASE, Web of Science and CINAHL for terms referring to GTPS. Studies that provided comparison of individuals with clinically characterized GTPS with healthy controls were included. Study quality was rated with the Joanna Briggs Institute Critical Appraisal Checklist for Cross Sectional Studies. Standardized mean differences were calculated and supported by narrative synthesis or meta-analyses where appropriate. Certainty of evidence was assessed based on the GRADE guidelines.

RESULTS

The search revealed 2798 studies, of which 13 studies from five research groups were included. There were 229 participants with at least three months duration of GTPS and 193 control participants. Individuals with GTPS displayed larger greater trochanteric width, greater body mass index, lower hip abductor muscle strength, higher hip abductor muscle activity, altered single leg loading and gait parameters including shorter step length and velocity. No studies investigating psychological features or sensory perception were identified. Quality of life was investigated in a single study.

CONCLUSIONS

Compared to healthy controls, participants with GTPS are more overweight, have poorer hip abductor muscle function and altered gait parameters. Overall quality of evidence across studies was very low based on GRADE guidelines.

ICON PART-T 2019-International Scientific Tendinopathy Symposium Consensus: recommended standards for reporting participant characteristics in tendinopathy research (PART-T)

We aimed to establish consensus for reporting recommendations relating to participant characteristics in tendon research. A scoping literature review of tendinopathy studies (Achilles, patellar, hamstring, gluteal and elbow) was followed by an online survey and face-to-face consensus meeting with expert healthcare professionals (HCPs) at the International Scientific Tendon Symposium, Groningen 2018. We reviewed 263 papers to form statements for consensus and invited 30 HCPs from different disciplines and geographical locations; 28 completed the survey and 15 attended the meeting. There was consensus that the following data should be reported for cases and controls: sex, age, standing height, body mass, history of tendinopathy, whether imaging was used to confirm pathology, loading tests, pain location, symptom duration and severity, level of disability, comorbidities, physical activity level, recruitment source and strategies, and medication use history. Standardised reporting of participant characteristics aims to benefit patients and clinicians by guiding researchers in the conduct of their studies. We provide free resources to facilitate researchers adopting our recommendations.

Managing Achilles Pain (the MAP study) - A process evaluation of data collection methods

BACKGROUND

Process evaluations explore the way in which a study was conducted. The Managing Achilles Pain study (MAP study) had the primary aim of assessing the feasibility of the protocol for a future large longitudinal cohort study that would investigate the association and predictive relationship of self-efficacy, working alliance and expectations with outcome in the management of Achilles tendinopathy.

OBJECTIVES

This study aimed to evaluate the processes conducted in the MAP study by exploring the acceptability of the study procedures from the participants' and physiotherapists' perspectives.

DESIGN

A qualitative evaluation using semi-structured telephone interviews.

METHOD

All physiotherapists and participants who participated in the MAP study were invited. Data from physiotherapists (n = 6) and participants (n = 7) were transcribed and analysed using the Framework Approach.

FINDINGS

From the physiotherapists' perspective 4 themes were identified relating to obstacles; (1) access to participants; (2) recall; (3) visibility; (4) time, and 4 themes were identified relating to facilitating success; (1) training; (2) motivation; (3) incentives; (4) simplicity. From the participants' perspective 2 themes were identified relating to obstacles; (1) information from the physiotherapist; (2) follow up, 3 themes were identified relating to facilitating success; (1) motivation; (2) website; (3) questionnaire, and 1 theme relating to unintended consequences of participating in the study; positive experience.

CONCLUSIONS

Although clinicians are enthused to be involved in research, organisational factors impact levels of engagement. Key influences to optimising the potential success of a study include the publicising of the study; optimising verbal recruitment strategies; and clarity in communication.

What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review

OBJECTIVES

To identify common recommendations for high-quality care for the most common musculoskeletal (MSK) pain sites encountered by clinicians in emergency and primary care (spinal (lumbar, thoracic and cervical), hip/knee (including osteoarthritis [OA] and shoulder) from contemporary, high-quality clinical practice guidelines (CPGs).

DESIGN

Systematic review, critical appraisal and narrative synthesis of MSK pain CPG recommendations.

ELIGIBILITY CRITERIA

Included MSK pain CPGs were written in English, rated as high quality, published from 2011, focused on adults and described development processes. Excluded CPGs were for: traumatic MSK pain, single modalities (eg, surgery), traditional healing/medicine, specific disease processes (eg, inflammatory arthropathies) or those that required payment.

DATA SOURCES

Four scientific databases (MEDLINE, Embase, CINAHL and Physiotherapy Evidence Database) and four guideline repositories.

RESULTS

6232 records were identified, 44 CPGs were appraised and 11 were rated as high quality (low back pain: 4, OA: 4, neck: 2 and shoulder: 1). We identified 11 recommendations for MSK pain care: ensure care is patient centred, screen for red flag conditions, assess psychosocial factors, use imaging selectively, undertake a physical examination, monitor patient progress, provide education/information, address physical activity/exercise, use manual therapy only as an adjunct to other treatments, offer high-quality non-surgical care prior to surgery and try to keep patients at work.

CONCLUSION

These 11 recommendations guide healthcare consumers, clinicians, researchers and policy makers to manage MSK pain. This should improve the quality of care of MSK pain.

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.

Modifiable risk factors for patellar tendinopathy in athletes: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis identifying (1) potential modifiable risk factors and (2) associated modifiable factors for patellar tendinopathy in athletes.

DESIGN

A systematic review and meta-analysis was conducted. Risk of bias was assessed using the Newcastle-Ottawa Scale and grouped based on study design. Meta-analytic statistics were performed for items reported by five or more studies. A strength of evidence rating is provided for items not appropriate for meta-analysis.

DATA SOURCES

PubMed, Web of Science, Scopus and Cinahl were searched on 14 November 2017.

ELIGIBILITY CRITERIA

Quantitative, original research reporting potential modifiable risk factors or associated factors, comparing athletes with patellar tendinopathy with a group without the injury.

RESULTS

862 records were screened and 31 articles were included (6 prospective, 25 cross-sectional). There was a lack of strong evidence for any potential modifiable risk factor or associated factors. There was limited or conflicting evidence that decreased ankle dorsiflexion range of motion, decreased posterior thigh and quadriceps flexibility, greater volume of jump training, more volleyball sets played per week, greater countermovement jump (CMJ) height and greater activity volume are potential modifiable risk factors. Meta-analysis supported greater activity volume (Cohen's d=0.22, 95% CI 0.06 to 0.39, p=0.008), higher body weight (0.36, 0.17 to 0.55, p<0.001) and greater CMJ height (0.31, 0.07 to 0.56, p=0.01) as associated modifiable factors.

CONCLUSIONS

There is a lack of strong evidence for any potential modifiable risk factors or associated factors. Factors with lower levels of support may be of interest in designing prevention programmes but require further research in high-quality, prospective studies.

Return to Sport in Athletes with Midportion Achilles Tendinopathy: A Qualitative Systematic Review Regarding Definitions and Criteria

Background

Midportion Achilles tendinopathy (AT) can cause long-term absence from sports participation, and shows high recurrence rates. It is important that the decision to return to sport (RTS) is made carefully, based on sharply delimited criteria. Lack of a well-defined definition and criteria hampers the decision to RTS among athletes with AT, and impedes comparison of RTS rates between different studies.

Objective

The aim of this study was to systematically review the literature for definitions of, and criteria for, RTS in AT research.

Study Design

Qualitative systematic review.

Methods

The PubMed, EMBASE, Cochrane, CINAHL, PEDro, and Scopus electronic databases were searched for articles that reported on the effect of a physiotherapeutic intervention for midportion AT. Article selection was independently performed by two researchers. Qualitative content analysis was used to analyze the included studies and extract definitions of, and criteria for, RTS.

Results

Thirty-five studies were included in the content analysis, showing large variety in both the definitions and criteria. Thirty-two studies reported a definition of RTS, but only 19 studies described the criteria for RTS. The content analysis revealed that ‘reaching pre-injury activity/sports level, with the ability to perform training and matches without limitations’, ‘absence of pain’, and ‘recovery’ were the main content categories used to define RTS. Regarding the criteria for RTS, eight different content categories were defined: (1) ‘level of pain’; (2) ‘level of functional recovery’; (3) ‘recovery of muscle strength’; (4) ‘recovery of range of motion’; (5) ‘level of endurance of the involved limb’; (6) ‘medical advice’; (7) ‘psychosocial factors’; and (8) ‘anatomical/physiological properties of the musculotendinous complex’. Many criteria were not clearly operationalized and lacked specific information.

Conclusions

This systematic review shows that RTS may be defined according to the pre-injury level of sports (including both training and matches), but also with terms related to the absence of pain and recovery. Multiple criteria for RTS were found, which were all related to level of pain, level of functional recovery, muscular strength, range of motion, endurance, medical advice, psychosocial factors, or anatomical/physiological properties of the Achilles tendon. For most of the criteria we identified, no clear operationalization was given, which limits their validity and practical usability. Further research on how RTS after midportion AT should be defined, and which criteria should be used, is warranted.

PROSPERO Registration Number

CRD42017062518.

Electronic supplementary material

The online version of this article (10.1007/s40279-017-0833-9) contains supplementary material, which is available to authorized users.

A service evaluation and improvement project: a three year systematic audit cycle of the physiotherapy treatment for Lateral Epicondylalgia

OBJECTIVES

To improve outcomes of physiotherapy treatment for patients with Lateral Epicondylalgia.

DESIGN

A systematic audit and quality improvement project over three phases, each of one year duration.

SETTING

Salford Royal NHS Foundation Trust Teaching Hospital Musculoskeletal Physiotherapy out-patients department.

PARTICIPANTS

n=182.

INTERVENTIONS

Phase one - individual discretion; Phase two - strengthening as a core treatment however individual discretion regarding prescription and implementation; Phase three - standardised protocol using high load isometric exercise, progressing on to slow combined concentric & eccentric strengthening.

MAIN OUTCOME MEASURES

Global Rating of Change Scale, Pain-free grip strength, Patient Rated Tennis Elbow Evaluation, Tampa Scale of Kinesophobia-11.

RESULTS

Phase three demonstrated a reduction in the average number of treatments by 42% whilst improving the number of responders to treatment by 8% compared to phase one. Complete cessation of non-evidence based treatments was also observed by phase three.

CONCLUSIONS

Strengthening should be a core treatment for LE. Load setting needs to be sufficient. In phase three of the audit a standardised tendon loading programme using patient specific high load isometric exercises into discomfort/pain demonstrated a higher percentage of responders compared to previous phases.

The experience of living with patellofemoral pain-loss, confusion and fear-avoidance: a UK qualitative study

OBJECTIVES

To investigate the experience of living with patellofemoral pain (PFP).

DESIGN

Qualitative study design using semistructured interviews and analysed thematically using the guidelines set out by Braun and Clarke.

SETTING

A National Health Service physiotherapy clinic within a large UK teaching hospital.

PARTICIPANTS

A convenience sample of 10 participants, aged between 18 and 40 years, with a diagnosis of PFP and on a physiotherapy waiting list, prior to starting physiotherapy.

RESULTS

Participants offered rich and detailed accounts of the impact and lived experience of PFP, including loss of physical and functional ability; loss of self-identity; pain-related confusion and difficulty making sense of their pain; pain-related fear, including fear-avoidance and 'damage' beliefs; inappropriate coping strategies and fear of the future. The five major themes that emerged from the data were: (1) impact on self; (2) uncertainty, confusion and sense making; (3) exercise and activity beliefs; (4) behavioural coping strategies and (5) expectations of the future.

CONCLUSIONS

These findings offer an insight into the lived experience of individuals with PFP. Previous literature has focused on pain and biomechanics, rather than the individual experience, attached meanings and any wider context within a sociocultural perspective. Our findings suggest that future research is warranted into biopsychosocial targeted interventions aimed at the beliefs and pain-related fear for people with PFP. The current consensus that best-evidence treatments consisting of hip and knee strengthening may not be adequate to address the fears and beliefs identified in the current study. Further qualitative research may be warranted on the impact and interpretation of medical terminology commonly used with this patient group, for example, 'weakness' and 'patellar mal-tracking' and its impact and interpretation by patients.

TRIAL REGISTRATION NUMBER

ISRCTN35272486; Pre-results.

Diagnosis and treatment of movement system impairment syndromes

BACKGROUND

Diagnoses and treatments based on movement system impairment syndromes were developed to guide physical therapy treatment.

OBJECTIVES

This masterclass aims to describe the concepts on that are the basis of the syndromes and treatment and to provide the current research on movement system impairment syndromes.

RESULTS

The conceptual basis of the movement system impairment syndromes is that sustained alignment in a non-ideal position and repeated movements in a specific direction are thought to be associated with several musculoskeletal conditions. Classification into movement system impairment syndromes and treatment has been described for all body regions. The classification involves interpreting data from standardized tests of alignments and movements. Treatment is based on correcting the impaired alignment and movement patterns as well as correcting the tissue adaptations associated with the impaired alignment and movement patterns. The reliability and validity of movement system impairment syndromes have been partially tested. Although several case reports involving treatment using the movement system impairment syndromes concept have been published, efficacy of treatment based on movement system impairment syndromes has not been tested in randomized controlled trials, except in people with chronic low back pain.

Patellar and Achilles tendinopathies are predominantly peripheral pain states: a blinded case control study of somatosensory and psychological profiles

Study design

Case–control design.

Background

Tendinopathy is characterised by pain on tendon loading. In persistent cases of upper limb tendinopathy, it is frequently associated with central nervous system sensitisation, whereas less commonly linked in the case of persistent lower limb tendinopathies.

Objectives

Compare somatosensory and psychological profiles of participants with persistent patellar (PT) and Achilles tendinopathies (AT) with pain-free controls.

Methods

A comprehensive battery of Quantitative Sensory Testing (QST) was assessed at standardised sites of the affected tendon and remotely (lateral elbow) by a blinded assessor. Participants completed the Victorian Institute of Sports Assessment, a health-related quality of life questionnaire, the Hospital Anxiety and Depression Scale and the Active Australia Questionnaire. Independent t-test and analysis of covariance (sex-adjusted and age-adjusted) were performed to compare groups.

Results

Participants with PT and AT did not exhibit differences from controls for the QST at the remote site, but there were differences at the affected tendon site. Compared with controls, participants with PT displayed significantly lower pressure pain threshold locally at the tendon (p=0.012) and fewer single limb decline squats before pain onset, whereas participants with AT only displayed fewer single heel raises before pain onset, but this pain was of a higher intensity.

Conclusion

PT and AT appear to be predominantly local not widespread pain states related to loading of tendons without significant features of central sensitisation.

Level of evidence

Level 4.

Beyond the tendon: Experiences and perceptions of people with persistent Achilles tendinopathy

BACKGROUND

Achilles tendinopathy (AT) is associated with persistent pain leading to a significant physical and psychological burden. Psychosocial factors are considered to be important mediators following exercise interventions. Despite the recognition of the importance of psychosocial variables in persistent MSK disorders, there is a distinct lack of qualitative research investigating psychosocial factors in AT.

PURPOSE

To qualitatively explore the perceptions and experiences of people with AT prior to an intervention study.

METHODOLOGY

A qualitative, interpretive description design was performed using semi-structured telephone interviews. The questioning route covered history of AT, perceived cause of AT, effect of AT pain, experience in managing AT, and perspective on prognosis of AT pain. Interviews were transcribed verbatim. The study has been reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) checklist. To facilitate the rigor of methodology and the transparency of the research process an audit trail was created.

RESULTS

Eight participant's (Five male and three female). Four main themes were identified in the data: (i) pain as a feature of everyday life; (ii) experience with the management process; (iii) identifying with and self-managing AT, and (iv) looking to the future.

CONCLUSIONS

This study suggests that persistent AT is associated with a significant psychosocial impact, particularly in terms of participation in daily life and valued activities. Better understanding the experiences and personal impacts of AT may enhance management of this persistent disorder, and facilitate individuals with AT complying with evidence-based approaches including exercise and pain reconceptualization.

Modern pain neuroscience in clinical practice: applied to post-cancer, paediatric and sports-related pain

•

Generalized hypersensitivity in post-cancer, sports-related and pediatric pain.

•

Rationale for pain education, stress management and cognition targeted exercises.

•

Need to change from a biomedical or psychosocial to an integrated approach.

In the last decade, evidence regarding chronic pain has developed exponentially. Numerous studies show that many chronic pain populations show specific neuroplastic changes in the peripheral and central nervous system. These changes are reflected in clinical manifestations, like a generalized hypersensitivity of the somatosensory system. Besides a hypersensitivity of bottom-up nociceptive transmission, there is also evidence for top-down facilitation of pain due to malfunctioning of the endogenous descending nociceptive modulatory systems. These and other aspects of modern pain neuroscience are starting to be applied within daily clinical practice. However, currently the application of this knowledge is mostly limited to the general adult population with musculoskeletal problems, while evidence is getting stronger that also in other chronic pain populations these neuroplastic processes may contribute to the occurrence and persistence of the pain problem. Therefore, this masterclass article aims at giving an overview of the current modern pain neuroscience knowledge and its potential application in post-cancer, paediatric and sports-related pain problems.