An international consensus definition for contextual factors: findings from a nominal group technique

A narrative review of the placebo effect: historical roots, current applications, and emerging insights

PURPOSE

Placebo is a term to define physiologically inactive compounds used in treatment that causes physical and emotional changes. The placebo effect, driven by expectation and conditioning, plays a significant role in various conditions like pain, depression, and Parkinson's disease, while the nocebo effect can hinder treatment outcomes. Understanding mechanisms such as neuromodulation and genetics has gained importance in modern medicine. This review aims to explore the clinical relevance of placebo responses, particularly in neuropsychiatric disorders, and their potential in personalized medicine. By integrating placebo research into healthcare, it highlights opportunities to enhance treatment efficacy, improve patient well-being, and reduce reliance on pharmacological interventions.

METHODS

A comprehensive literature search was conducted in PubMed, Scopus, and Google Scholar databases. Recent studies were reviewed to evaluate placebo effects, and the variability of the placebo response in neuropsychiatric disorders was summarized.

RESULTS

Placebo effects significantly impact treatment outcomes across various conditions, including Parkinson's disease, depression, pain syndromes, and epilepsy. The mechanisms involve neurobiological and psychological factors, with evidence suggesting that placebo interventions can modulate neurotransmitter activity and improve patient well-being.

CONCLUSION

Integrating placebo research into clinical practice may enhance treatment outcomes, reduce drug dependency, and support personalized medicine by tailoring interventions to individual placebo responsiveness. Understanding placebo and nocebo mechanisms can optimize therapeutic strategies while minimizing unnecessary pharmacological treatments.

Neighborhood matters: An exploration of neighborhood-level disadvantage and cancer preventive behaviors in Hispanic youth with unhealthy weight

OBJECTIVES

The present study aimed to assess the associations between the youth's cancer preventive behaviors (CPB) (i.e., healthy dietary intake and physical activity), parent stress, parent socio-demographic characteristics (i.e., education, household income, and marital status), and neighborhood influences measured by the Area Deprivation Index (ADI) in a sample of Hispanic families who have youth with unhealthy weight. Additionally, we examined whether parent stress mediated the relationship between ADI and youth CPB.

METHODS

Baseline data from 280 Hispanic youth (Mage = 13.01 ± 0.83; 52.1 % females; MBody Mass Index (BMI) Percentile = 94.55 ± 4.15) and their parents (Mage = 41.87 ± 6.49; 88.2 % females) who enrolled in an RCT were used. Self-reported data on youth dietary intake and physical activity, parent stress, and parent socio-demographic characteristics were collected. Neighborhood impact was examined using ADI, a validated measure to classify neighborhood disadvantage (e.g., housing quality and neighborhood income) using data from the US Census Bureau. Structural Equation Modeling was used (CPB as a latent variable) to evaluate the study model.

RESULTS

Our findings indicated significant associations between ADI and youth CPB (b = -0.17, p = .019), and parent stress (b = 0.23, p = .001). However, parent stress did not mediate the relationship between youth ADI and CPB.

CONCLUSION

Youth living in disadvantaged neighborhoods report less engagement in cancer preventive behaviors including poorer food intake quality and less physical activity, which may increase their risk of cancer. Future research should evaluate neighborhood resources to encourage physical activity and healthy eating.

Contextual Factors Affecting Adherence Revealed by Old Patients with Heart Failure in Hospital and Primary Care Interactions: A Descriptive Study

Introduction

Old patients with heart failure are a vulnerable patient group facing various challenges, specifically during the transition from hospital to home. Non-biomedical factors, or "contextual factors", such as patient attitudes and social support, can influence treatment adherence. However, their role in clinical interactions is not well understood. This study aimed to identify and describe how and when these factors manifest during clinical interactions in the hospital-to-home transition.

Methods

We audio-recorded 42 old patients with heart failure admitted to hospital interacting with their physicians at: 1. the first ward visit, 2. discharge visit, 3. first primary care visit after discharge. Based on an umbrella review, we developed a list of 48 factors known to affect adherence among cardiovascular patients. Patient utterances from the recordings containing information on one of these factors (contextual indicators (CI)) were extracted and categorized according to the type of factor, mentioned impact, and being a facilitator or barrier to adherence.

Results

From the 105 audio recordings, 742 CI were identified, each interaction containing an average of 7 CI (SD = 4.2; median = 6). CI considered to have a potential impact on patient's life or adherence were overall evenly split between facilitators (n = 82, 42%) and barriers (n = 115, 58%), and both types of CI appeared in most patient trajectories. The most salient barrier CI was related to patients' concerns regarding medications side effects and regimen complexity, while CI facilitators were more commonly related to patients' knowledge, motivation and social support.

Discussion

The findings from this study provide insights for clinicians to the main types of non-biomedical factors revealed by old patients with heart failure in medical interactions, which affect their treatment adherence. Clinicians should particularly consider patient concerns regarding medications' side effects and the regimen complexity as important aspects to discuss, leveraging on motivational and social resources if present.

Enhancing health equity considerations in guidelines: health equity extension of the GIN-McMaster Guideline Development Checklist

Background

Practice guidelines may reduce health inequities by addressing preventable and unjust differences in health. However, health equity considerations are often inadequately integrated into the guideline planning and development process. This article describes a pragmatic approach to enhancing health equity considerations within guidelines by introducing an extension to the GIN-McMaster Guideline Development Checklist (GDC).

Methods

We reviewed the latest guidance on enhancing health equity considerations in guideline development to draft the checklist and deployed a global online survey from March 27th, 2024, to May 13th, 2024 to gather consensus. We conducted a methodological review of guideline development handbooks to identify best practices in health equity considerations. An advisory board comprised of diverse interest-holders informed the development of the checklist. We made revisions based on the survey feedback and review findings.

Findings

We present 21 extension items spanning 16 of the 18 guideline development topics from the GIN-McMaster GDC. Key additions include planning for engagement with individuals experiencing inequities in guideline development activities, applying an equity lens, and considering health equity in recommendation formulation, dissemination and implementation strategies. This checklist gives value to lived experiences to enrich health equity assessments, complementing empirical evidence to inform guideline recommendations. Guideline developers should assess guideline sensitivity to health equity to determine resource prioritization for optimal implementation of the extension items.

Interpretation

The GIN-McMaster health equity extension provides guidance for the streamlined integration of health equity considerations throughout the guideline development process. Using this tool alongside the original GIN-McMaster GDC may lead to more equitable and impactful guidelines.

Funding

This project was partially funded by Public Health Agency of Canada. The funder was not involved in the conceptualization or design or the conduct of the project.

Categorizing Treatment Mechanisms for Complementary and Integrative Musculoskeletal Interventions

Treatment mechanisms (TM) reflect the steps or processes through which a treatment unfolds. However, TM research faces challenges due to inconsistent terminology and varying measurement approaches for each mechanism, which creates confusion and controversy among clinicians and scientists. In this paper, we: 1) define key terms associated with TM, 2) provide recommended categories of study that reflect intervention domains, and 3) present examples of measures of TM within the defined categories. Our recommended definitions differentiate associated TM (a finding that occurs following administration of a treatment that may or may not influence outcomes) from causal TM (which directly affects the clinical outcome). When measuring causal TM, we recommend that researchers consider three potential categories of interventional domains: a) anatomical, b) psychological/cognitive and c) behavioral. Lastly, we argue that within each interventional domain, TM can be measured across a spectrum that includes physiological (e.g., brain activity, nerve activity, biomarkers, etc.) and functional (e.g., range of motion, stiffness, cognition measures, etc.) mechanisms. Measuring both physiological and functional mechanisms improves the likelihood of understanding the complexity of clinical recovery. Harmonizing TM terminology, categories, and measurements across a spectrum, while providing examples of each, may reduce confusion and assist researchers and funding sources in targeting specific mechanistic-related questions.

Synthesis of expert opinions on fluid management in severe sepsis: A contextual review of human albumin and crystalloids

BACKGROUND

Sepsis is a critical condition associated with high mortality rates that necessitates effective fluid resuscitation. Crystalloids are widely utilized; however, human albumin solutions have been attributed potential oncotic and anti-inflammatory benefits. Given the ongoing debate and the absence of definitive empirical evidence, expert opinions provide valuable insights into the contextual and practical aspects of fluid management.

OBJECTIVES

This review synthesizes expert opinions on the utilization of albumin compared to crystalloids in critically ill sepsis patients, emphasizing the contextual and practical considerations rather than drawing conclusions about clinical efficacy.

METHODS

Following the Joanna Briggs Institute (JBI) guidelines for systematic reviews of text and opinions, databases and registries were searched from 2015 to 2024. Two reviewers independently screened sources. Data extraction was conducted by one reviewer and verified by another reviewer. Of 1,917 sources, 38 met the inclusion criteria. Findings were synthesized narratively.

RESULTS

Expert consensus emphasizes crystalloids as the preferred first-line fluid for sepsis due to their safety, cost-effectiveness, and availability. Albumin is conditionally recommended in specific scenarios such as severe hypoalbuminemia, high vasopressor requirements, or volume-sensitive conditions. While theoretical benefits of albumin, including enhanced volume expansion and reduced fluid overload, are recognized, evidence for consistent clinical outcomes remains limited. Experts underscore the importance of individualized management tailored to patient-specific factors and dynamic monitoring, aligning with guideline recommendations that advise against routine albumin use.

CONCLUSIONS

This review highlights the contextual and practical aspects of fluid management in sepsis, underscoring the predominance of crystalloids as the initial choice. Expert insights suggest that albumin may have a supplementary role in specific clinical scenarios. These findings provide a refined understanding of current practice and serve as a foundation for informed decision-making and future research.

TRIAL REGISTRY

PROSPERO; Registration Number: CRD42024580521; URL: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=580521.

Negative expectations and related nocebo effects in shoulder pain: a perspective for clinicians and researchers

The nocebo effect, a phenomenon wherein negative expectations can worsen symptoms, is increasingly acknowledged within the context of musculoskeletal conditions. While experimental evidence has, to some extent, examined negative expectations in shoulder pain, their specific relationship with nocebo effects and their manifestation in clinical practice remains unexplored. In this perspective, clinicians and researchers are guided by first examining the psychobiology and neurophysiology underlying nocebo effects from a basic science standpoint, thereby equipping clinicians with a robust understanding of the phenomenon. What are considered the primary potential sources of nocebo effects in individuals with shoulder pain are then outlined - namely, diagnostic labels, diagnostic imaging and special tests, the medicalization of normality, and overtreatment. Practical clinical strategies are subsequently proposed to mitigate nocebo effects arising from these sources. Finally, the research implications for advancing the study of nocebo effects in people with shoulder pain are discussed. Overall, this perspective provides a comprehensive overview of the impact of negative expectations and associated nocebo effects on shoulder pain outcomes. By identifying potential sources of nocebo effects that may emerge in everyday clinical practice, guidance on mitigating related negative expectations in patients with shoulder pain is offered.

The Effectiveness of Spinal Manipulative Therapy in Treating Spinal Pain Does Not Depend on the Application Procedures: A Systematic Review and Network Meta-analysis

OBJECTIVE: To assess whether spinal manipulative therapy (SMT) application procedures (ie, target, thrust, and region) impacted changes in pain and disability for adults with spine pain. DESIGN: Systematic review with network meta-analysis. LITERATURE SEARCH: We searched PubMed and Epistemonikos for systematic reviews indexed up to February 2022 and conducted a systematic search of 5 databases (MEDLINE, EMBASE, CENTRAL [Cochrane Central Register of Controlled Trials], PEDro [Physiotherapy Evidence Database], and Index to Chiropractic Literature) from January 1, 2018, to September 12, 2023. We included randomized controlled trials (RCTs) from recent systematic reviews and newly identified RCTs published during the review process and employed artificial intelligence to identify potentially relevant articles not retrieved through our electronic database searches. STUDY SELECTION CRITERIA: We included RCTs of the effects of high-velocity, low-amplitude SMT, compared to other SMT approaches, interventions, or controls, in adults with spine pain. DATA SYNTHESIS: The outcomes were spinal pain intensity and disability measured at short-term (end of treatment) and long-term (closest to 12 months) follow-ups. Risk of bias (RoB) was assessed using version 2 of the Cochrane RoB tool. Results were presented as network plots, evidence rankings, and league tables. RESULTS: We included 161 RCTs (11 849 participants). Most SMT procedures were equal to clinical guideline interventions and were slightly more effective than other treatments. When comparing inter-SMT procedures, effects were small and not clinically relevant. A general and nonspecific rather than a specific and targeted SMT approach had the highest probability of achieving the largest effects. Results were based on very low- to low-certainty evidence, mainly downgraded owing to large within-study heterogeneity, high RoB, and an absence of direct comparisons. CONCLUSION: There was low-certainty evidence that clinicians could apply SMT according to their preferences and the patients' preferences and comfort. Differences between SMT approaches appear small and likely not clinically relevant. J Orthop Sports Phys Ther 2025;55(2):1-14. Epub 7 January 2025. https://doi.org/10.2519/jospt.2025.12707.

Rehabilitation Management of Neck Pain-Development of a Diagnostic Framework Based on the Pain and Disability Drivers Management Model

RATIONALE

Neck pain is a major cause of disability worldwide, and current rehabilitation strategies show limited effectiveness. Subgrouping patients by their primary pain and disability drivers can help tailor treatments. At this end, the Pain and Disability Drivers Management (PDDM) was developed and has demonstrated preliminary effectiveness in the management of low back pain. Nevertheless, the PDDM model was only validated for this population. Adapting this framework to patients with neck pain would provide a more global view of the patient's experience of pain and support a genuine biopsychosocial intervention.

AIMS AND OBJECTIVES

The aim of this study was to develop and validate the content of the PDDM model for patients living with neck pain.

METHODS

Through a modified DELPHI study design, participants with clinical and research expertize in rehabilitation of neck pain were invited to participate. A questionnaire was developed using literature reviews and endorsed by a steering committee. The relevance of each element of the newly adapted model was evaluated on a 4-point Likert scale. An item reached consensus if it obtained the predefined threshold of > 78% "relevant" and "very relevant." Participants left comments on terminology and recommended items to add in early rounds. Quantitative and qualitative analyses were performed.

RESULTS

An invitation was sent to 1650 potential participants, from which 155 accessed the survey, 64 completed the first round and 55 the second round. A total of 70 elements met consensus and were distributed across six domains: "Nociceptive pain drivers", "nociplastic pain drivers," "drivers associated with neuropathic pain", "comorbidity drivers", "cognitive-emotional drivers" and "environmental or lifestyle drivers, and social determinants of health."

CONCLUSION

Through a modified DELPHI study, the PDDM model was updated and adapted to people with neck pain. Subsequent steps include clinical integration and measures of efficacy when used for assessment/treatment.

Effect of Transcutaneous Auricular Vagus Nerve Stimulation in Chronic Low Back Pain: A Pilot Study

Background/Objectives: Chronic low back pain (CLBP) is a common condition with limited long-term treatment options. Vagus nerve stimulation (VNS) has shown potential for pain improvement, but its use in CLBP remains underexplored. Our aim was to evaluate the efficacy, feasibility and tolerability of transcutaneous auricular vagus nerve stimulation (taVNS) in reducing pain and improving functional outcomes in CLBP patients. Methods: Thirty adults with CLBP (VAS ≥ 40/100) participated in this open-label pilot study (NCT05639270). Patients were treated with a taVNS device on the left ear for 30 min daily over a period of 3 months. The primary outcome was a reduction in pain intensity (VAS) at 1 month. Secondary outcomes included pain intensity at 3 months, disability (Oswestry Disability Index, ODI), quality of life (EQ-5D-5L), catastrophizing and psychological distress. In addition, compliance and adverse events were monitored. Results: After 1 month, 27 patients were evaluated. VAS scores decreased significantly by 16.1 (SD = 17.9) mm (p < 0.001) and by 22.5 (25) mm (p < 0.001) after 3 months (24 patients were analyzed). Functional disability improved with an average reduction in ODI of 11.9 (11.1) points (p < 0.001) after 3 months. Other patient-reported outcomes also improved significantly over the 3-month period. Overall, 51.9% of the patients achieved clinically meaningful pain reduction (≥20 mm), and no serious adverse events were reported. Treatment adherence was good, with half of the patients achieving 80% adherence. Conclusions: This pilot study suggests that taVNS is a feasible, safe and potentially effective treatment for CLBP that warrants further investigation in a randomized controlled trial compared to sham stimulation.

Integrated manual therapies: IASP taskforce viewpoint

Introduction

Manual therapy refers to a range of hands-on interventions used by various clinical professionals, such as osteopaths, osteopathic physicians, chiropractors, massage therapists, physiotherapists, and physical therapists, to treat patients experiencing pain.

Objectives

To present existing evidence of mechanisms and clinical effectiveness of manual therapy in pain.

Methods

This Clinical Update focuses on the 2023 International Association for the Study of Pain Global Year for Integrative Pain Care. Current models of manual therapy and examples of integrative manual therapy are discussed.

Results

The evolution of concepts in recent years are presented and current gaps in knowledge to guide future research highlighted. Mechanisms of manual therapy are discussed, including specific and contextual effects. Findings from research on animal and humans in manual therapy are presented including on inflammatory markers, fibrosis, and behaviours. There is low to moderate levels of evidence that the effect sizes for manual therapy range from small to large for pain and function in tension headache, cervicogenic headache, fibromyalgia, low back pain, neck pain, knee pain, and hip pain.

Conclusion

Manual therapies appear to be effective for a variety of conditions with minimal safety concerns. There are opportunities for manual therapies to integrate new evidence in its educational, clinical, and research models. Manual therapies are also well-suited to fostering a person-centred approach to care, requiring the clinician to relinquish some of their power to the person consulting. Integrated manual therapies have recently demonstrated a fascinating evolution illustrating their adaptability and capacity to address contemporary societal challenges.

Adolescent and Parent Experiences and Perceived Effectiveness of Physical Interventions for Chronic Musculoskeletal Pain: A Qualitative Study

INTRODUCTION

There is a paucity of evidence on the effectiveness of physical interventions for chronic musculoskeletal pain affecting adolescents. This study explored adolescent and parent experiences and perceived effectiveness of physical intervention for chronic musculoskeletal pain in the UK.

METHODS

Using semi-structured interviews, 21 young people receiving treatment for chronic musculoskeletal pain and 21 parents were interviewed regarding their healthcare experiences. Data regarding experiences of physical interventions were analysed in this secondary qualitative analysis using inductive reflexive thematic analysis.

RESULTS

Three themes that captured why adolescents and parents perceived physical interventions to be effective or not were (1) feeling in control, (2) the right person and an explanation that makes sense and (3) make a difference to me not my foot.

DISCUSSION

Core concepts that appeared to influence the perceived effectiveness of physical interventions from the perspectives of adolescents and parents included facilitating adolescent autonomy, establishing a therapeutic alliance on the basis of trust and focusing physiotherapy treatment on meaningful participation in life.

CONCLUSION

There were no ideal physical interventions. The themes convey the importance of therapeutic alliance, intervention context and the need for personalised care.

Chronic pain patients' evaluations of consultations: A matter of high expectations or expectations unmet?

OBJECTIVE

This study tests two hypotheses about spine pain patients' expectations for consultations and their negative evaluations. High expectations may be impractical or unachievable and can set patients up for disappointment. Unmet expectations are the absolute difference between expectations before the visit and perceptions of expectations actually enacted.

METHOD

We conducted a single-site prospective study using pre- and post-consultation surveys. Patients (N = 200) were English-speaking individuals aged 18-75 presenting for an initial consultation for musculoskeletal pain. Analyses were conducted in SPSS v. 28.0 using mixed modeling to account for interdependence among cases.

RESULTS

Contrary to initial predictions, higher pre-consultation expectations for shared decision-making were positively linked to post-consultation satisfaction, trust, and agreement. Exceeding expectations in shared decision-making, history-taking, examination, and interpersonal skills significantly enhanced post-consultation outcomes.

CONCLUSIONS

Results support the unmet expectations hypothesis over the high expectations hypothesis. Increased expectations and exceeding these expectations in key areas of patient-physician interaction were positively associated with improved consultation outcomes.

PRACTICE IMPLICATIONS

Findings highlight the importance of exceeding multifaceted patient expectations in physician evaluations. Yet, physicians must first understand the nature and source of each patient's expectations pre-consultation, which vary across individuals in aspirational and realistic dimensions.

A consensus-based agreement on a definition of a process variable: findings from a New Zealand nominal group technique study

BACKGROUND

Musculoskeletal pain and disability are leading causes of reduced health and significant economic costs worldwide. Individualised, and evidence-based treatment approaches for specific musculoskeletal conditions aimed at improving patient outcomes and costs have not been successful. Recently authors have suggested that the 'process' of how care is implemented within a health system needs to be considered as an influencer on patient outcomes. With the rising prevalence of musculoskeletal conditions and the burgeoning costs associated with their treatment, it seems timely that new research focusing on process variables and their influence on patients with musculoskeletal conditions is explored. Before such studies can take place, a modern definition of a process variable within a musculoskeletal care pathway is needed to anchor future research endeavours. Therefore, the aim of this study was to establish a consensus-based definition of a process variable within a musculoskeletal care pathway, based on a New Zealand setting.

METHODS

This study used a virtual nominal group technique and took place in July 2023 using a Microsoft Teams platform. A nominal group technique employs a structured approach to generate information and solutions to problems that can then be prioritised through group discussion and consensus. It is unique because it allows expert participants to explore using in-depth inquiry, areas previously unidentified or not yet investigated. There was an inclusion criterion and the participants completed pre-work before the two-hour five stage virtual meeting. The Auckland University of Technology Ethics Committee (AUTEC) approved this study (AUTEC 23/94).

RESULTS

The study included eight participants (five male, three female) who had extensive experience with the New Zealand ACC insurance scheme and the design, implementation, and administration of musculoskeletal care pathways. The consensus definition was 'A health process variable is any modifiable factor in a health process or pathway that can be quantified and measured and that if varied may achieve a different operational or patient outcome'.

CONCLUSIONS

This study of New Zealand-based experts has formed a consensus-based agreement for a definition of a process variable in a musculoskeletal care pathway. This is an important first step in developing our understanding of process variables, and further research is needed to establish the link between process variables and their influence on the outcomes of patients with musculoskeletal conditions.

Global trends and performance of dry needling from 2004 to 2024: a bibliometric analysis

Background

Many doctors are incorporating dry needling into their clinical practice. Despite this growing trend, there has not been a comprehensive bibliometric analysis conducted in this field. Thus, this study aims to investigate the current research landscape, key research contributors, and popular research topics in dry needling, and to analyze the developmental trends within this area of study.

Methods

The study utilized the Web of Science Core Collection (WoSCC) as the main data source. Scientific literature was gathered through title (TI) searches for original clinical research papers on dry needling published between 2004 and 2024, using 'dry needling' or 'dry needle' as the search term. Statistical analyses and visualizations of the literature information, such as keywords, countries, research institutions, and authors, were conducted using the bibliometric.com online platform and VOSviewer. This approach aimed to statistically analyze and visualize the key research entities, hotspots, and frontiers in dry needling research. Additionally, the study delved into collaborative networks, research outputs, hot topics, and trends within the field of dry needling.

Results

This investigation encompassed 468 publications, with the year 2021 topping the charts for the highest publication output, amassing a total of 271 articles. The journal "Acupuncture in Medicine" emerged as the most frequently cited publication. The most impactful article was titled "Acupuncture and dry-needling for low back pain: An updated systematic review within the framework of the Cochrane Collaboration." Spain took the lead as the most productive country in this domain, with the United States closely following. Cesar Fernández-de-las-Peñas emerged as the most prolific author in the field. The Universidad Rey Juan Carlos in Spain was recognized as the most productive institution for research in dry needling. As for journal keywords, "dry needling," "trigger point," and "myofascial pain syn-drome" were the triumvirate of terms most recurrently encountered.

Conclusion

The field of dry needling research has witnessed significant growth in recent years, characterized by the emergence of novel trends such as comparative studies with acupuncture, exploration into the mechanisms of action, and a transition toward interdisciplinary approaches. As medical models evolve, the focus is expanding from the exclusive treatment of muscle pain to broader applications. Despite this progress, the domain is underscored by a paucity of large-scale, multicenter clinical trials and animal studies. There exists an imperative for enhanced collaboration among academic and research institutions. A more profound exploration and comprehensive research endeavors are essential to enhance our understanding and broaden the clinical application of dry needling techniques.

Fire needle therapy for the treatment of cancer pain: a protocol for the systematic review and meta-analysis

Background

Cancer patients frequently suffer pain as one of their symptoms. It includes acute and chronic pain and is one of the most feared symptoms for patients. About one-third of adults actively undergoing cancer treatment suffer from pain related to their condition. Cancer pain control remains suboptimal due to a lack of assessment, knowledge, and access. Fire needle therapy, a traditional Chinese medicine, offers a potentially beneficial addition to current pain management approaches. This protocol outlines a systematic review and meta-analysis to compile evidence and examine the pain-relieving effects and safety of fire needle therapy for cancer patients.

Methods and analysis

We will systematically search China National Knowledge Infrastructure (CNKI), Wanfang Database, China Biology Medicine disc (CBM), China Science and Technology Journal Database (CSTJ or VIP), PubMed, Web of Science, Embase, Cochrane Central Registry of Controlled Trials (CENTRAL), Chinese Clinical Trial Registry (Chictr), Opengrey, Worldcat, and Scopus from inception through July 2023. Random control trials (RCTs) include all types of cancer patients (age ≥ 18 years) complaining of pain. The primary outcome will be changes in pain intensity measured by Visual Analogue Scale (VAS), Numerical Rating Scale (NRS), Neuropathic Pain Scale (NPS), or Brief Pain Inventory (BPI). Secondary outcomes include quality of life (EORTC QLQ-C30 and GCQ), performance status (KPS), times of burst pain, treatment response rate, the dose reduction of analgesic drugs, and side effects rates. Utilizing the Cochrane risk bias measurement tool: Risk of Bias 2 (RoB 2), the trials' quality will be evaluated, and meta-analysis will be performed using RevMan software (version 5.4).

Discussion

This systematic review will be the first comprehensive review of the literature to provide a meta-analysis of fire needle therapy for cancer pain, including only Random control trials (RCTs). For the sake of transparency and to avoid future duplication, the publication of this protocol offers a clear illustration of the procedures utilized in this evaluation. The results of our future studies may provide a new approach and theoretical basis for the treatment of cancer pain by medical oncology professionals.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023418609.

Interdisciplinary pain program participants with high catastrophizing scores improve function utilizing enriched therapeutic encounters and integrative health techniques: a retrospective study

Introduction

Pain catastrophizing describes helplessness, rumination, and magnification of a pain experience. High pain catastrophizing is an independent risk factor for disability, pain severity, inadequate treatment response, chronicity, and opioid misuse. Interdisciplinary pain programs (IPPs) are beneficial and cost-effective for individuals with chronic pain, but their functional impact on individuals with high pain catastrophizing is not well established. The emerging field of placebo studies suggests that patient-provider relationships, positive treatment expectations, and sociobiologically informed care trigger physiological responses that may enhance therapeutic interventions.

Methods

In this retrospective observational cohort study, we compared admission and discharge data for 428 adults with high-impact chronic pain (mean 8.5 years) who completed the Spaulding-Medford Functional Restoration Program (FRP). The interdisciplinary FRP team of physiatrists, behavioral health clinicians, physical therapists, and occupational therapists specializes in evidenced-based conventional rehabilitation, integrative health, and pain psychoeducation via enriched therapeutic encounters, fostering collaboration, validation, trust, self-efficacy, and positive expectations. Clinical outcome measures included the Canadian Occupational Performance Measure (COPM) assessing functional performance (COPM-PS) and satisfaction with function (COPM-SS), the Pain Numeric Rating Scale (NRS), the Pain Catastrophizing Scale (PCS), and the Patient Health Questionnaire-9 (PHQ-9).

Results

FRP participants with clinically elevated catastrophizing at baseline (PCS ≥30, mean PCS 39) achieved statistically significant improvements in function (mean delta -2.09, CHI2 = 15.56, p < 0.001), satisfaction with function (COPM-SS mean delta -2.50, CHI2 = 7.42, p = 0.007), pain (NRS mean delta 2.7), mood (PHQ-9 mean delta 1.87, p = 0.002), and catastrophizing (PCS mean delta 4.16, p < 0.001). Subgroup analysis revealed racial disparities in pain scores, and exploratory analysis showed a trend toward reducing opiate consumption.

Discussion

Despite the known association of adverse outcomes with high catastrophizing, FRP participation was associated with increased productive engagement, reduced pain, reduced maladaptive thought processes, and improved mood. Although causation and efficacy cannot be established from a retrospective design, this is the first study to identify functional improvement in patients with high-impact chronic pain and clinically relevant high pain catastrophizing who participate in an IPP combining conventional and complementary rehabilitation with psychoeducation. These enriched therapeutic encounters may enhance the treatment process by promoting trust, empathy, collaboration, and beneficial reframing of patients' experiences, expectations, and goals.

Hacking the Predictive Mind

According to active inference, constantly running prediction engines in our brain play a large role in delivering all human experience. These predictions help deliver everything we see, hear, touch, and feel. In this paper, I pursue one apparent consequence of this increasingly well-supported view. Given the constant influence of hidden predictions on human experience, can we leverage the power of prediction in the service of human flourishing? Can we learn to hack our own predictive regimes in ways that better serve our needs and purposes? Asking this question rapidly reveals a landscape that is at once familiar and new. It is also challenging, suggesting important questions about scope and dangers while casting further doubt (as if any was needed) on old assumptions about a firm mind/body divide. I review a range of possible hacks, starting with the careful use of placebos, moving on to look at chronic pain and functional disorders, and ending with some speculations concerning the complex role of genetic influences on the predictive brain.

Effects of buccal acupuncture on postoperative analgesia in elderly patients undergoing laparoscopic radical gastrectomy: a randomized controlled trial

Objective

This study aimed to evaluate the efficacy and safety of buccal acupuncture on postoperative analgesia, perioperative stress response and adverse events in elderly patients undergoing laparoscopic radical gastrectomy.

Methods

It was a prospective, outcome assessor-blinded, randomized controlled trial, involving 90 patients aged 65-80 years who were treated with an elective laparoscopic radical gastrectomy. They were randomly assigned to buccal acupuncture group (Group B) and control group (Group C). Buccal acupuncture was applied to patients of Group B before the induction of general anesthesia, while no additional application was given to those in Group C. Patient-controlled intravenous analgesia (PCIA) with sufentanil was postoperatively performed in both groups. Sufentanil consumption and the Visual Analog Scale (VAS) score within 48 h postoperatively were assessed as primary outcomes. Secondary outcomes included peripheral levels of stress markers, intraoperative consumptions of anesthetic drugs and postoperative recovery.

Results

Patients in Group B presented significantly lower VAS scores within 24 h and less consumption of sufentanil within 48 h postoperatively (both p < 0.01). The awaking time, time to extubation and length of stay were significantly shorter in Group B than in Group C (p = 0.005, 0.001 and 0.028, respectively). Compared with Group C, stress response and inflammatory response within 24 h postoperatively were also significantly milder in Group B.

Conclusion

The use of buccal acupuncture before general anesthesia induction favors the postoperative analgesic effect and recovery in elderly patients undergoing laparoscopic radical gastrectomy, the mechanism of which involves relieving postoperative stress response and inflammatory response.

Clinical trial registration

This study was registered in the Chinese Clinical Trial Registry (www.chictr.org.cn) on 15/06/2023 (ChiCTR2300072500).

Which Portion of Physiotherapy Treatments' Effect Is Not Attributable to the Specific Effects in People With Musculoskeletal Pain? A Meta-Analysis of Randomized Placebo-Controlled Trials

OBJECTIVE: We aimed to quantify the proportion not attributable to the specific effects (PCE) of physical therapy interventions for musculoskeletal pain. DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: We searched Ovid, MEDLINE, EMBASE, CINAHL, Scopus, PEDro, Cochrane Controlled Trials Registry, and SPORTDiscus databases from inception to April 2023. STUDY SELECTION CRITERIA: Randomized placebo-controlled trials evaluating the effect of physical therapy interventions on musculoskeletal pain. DATA SYNTHESIS: Risk of bias was evaluated using the Cochrane risk-of-bias tool for randomized trials (RoB 2). The proportion of physical therapy interventions effect that was not explained by the specific effect of the intervention was calculated, using the proportion not attributable to the specific effects (PCE) metric, and a quantitative summary of the data from the studies was conducted using the random-effects inverse-variance model (Hartung-Knapp-Sidik-Jonkman method). RESULTS: Sixty-eight studies were included in the systematic review (participants: n = 5238), and 54 placebo-controlled trials informed our meta-analysis (participants: n = 3793). Physical therapy interventions included soft tissue techniques, mobilization, manipulation, taping, exercise therapy, and dry needling. Placebo interventions included manual, nonmanual interventions, or both. The proportion not attributable to the specific effects of mobilization accounted for 88% of the immediate overall treatment effect for pain intensity (PCE = 0.88, 95% confidence interval [CI]: 0.57, 1.20). In exercise therapy, this proportion accounted for 46% of the overall treatment effect for pain intensity (PCE = 0.46, 95% CI: 0.41, 0.52). The PCE in manipulation excelled in short-term pain relief (PCE = 0.81, 95% CI: 0.62, 1.01) and in mobilization in long-term effects (PCE = 0.86, 95% CI: 0.76, 0.96). In taping, the PCE accounted for 64% of disability improvement (PCE = 0.64, 95% CI: 0.48, 0.80). CONCLUSION: The outcomes of physical therapy interventions for musculoskeletal pain were significantly influenced by factors not attributable to the specific effects of the interventions. Boosting these factors consciously to enhance therapeutic outcomes represents an ethical opportunity that could benefit patients. J Orthop Sports Phys Ther 2024;54(6):391-399. Epub 11 April 2024. doi:10.2519/jospt.2024.12126.

Contextual Factors-Enriched Standard Care on mechanical neck pain (ContextualizAR trial): Protocol for a randomised controlled trial

BACKGROUND

Understanding the influence of contextual factors (CFs) on interventions for mechanical neck pain (MNP) is essential for evidence-based practice in physical therapy. However, the specific effects and synergies of combining different CFs remain unclear.

OBJECTIVE

The primary purpose of this study will be to determine if a CFs-Enriched Standard Care (SC) approach is an effective treatment for MNP in terms of reducing pain and improving function.

METHODS

This will be an assessor-blinded, 2-group (1:1) randomised clinical trial (RCT) aiming to enrol 94 participants with neck pain persisting for more than 4 weeks. Both groups will undergo 4 weeks of SC twice weekly, following established clinical practice guidelines. In the intervention group, CFs will be enhanced, encompassing the physical, psychological, and social elements inherent in the clinical encounter, based on existing evidence. The primary outcomes will encompass changes in pain and disability after 4 weeks of treatment, with a follow-up reassessment at week 12 post-treatment. Secondary outcomes will include changes in Active Range of Motion, Global Rating of Change, and Satisfaction with treatment. The change between groups after treatment and at the 12-week follow-up will be reported for all outcomes, considering the difference from scores recorded at baseline.

RESULTS

We hypothesise that a 4-week CFs-Enriched SC approach will be superior to SC alone in terms of patient-reported disability and pain, with measurements conducted using the Northwick Park Neck Pain Questionnaire and the Numeric Pain Rating Scale, respectively.

CONCLUSION

This RCT rigorously assesses the effect of purposeful manipulation of CFs during MNP treatment. By elucidating the role of these factors, our findings have the potential to significantly refine clinical practice in managing MNP, thereby enhancing patient care, and advancing the fields of physical therapy and rehabilitation.

The use of a biopsychosocial model in the treatment of patients with chronic

OBJECTIVE

To explore the available knowledge on the application of biopsychosocial model (BPS) in patients with chronic low back pain (CLBP).

METHODS

A scoping review, including 32 papers that used a BPS to manage adult patients with CLBP, published in any language. Six different databases were searched.

RESULTS

According to the description of the protocols, most of them use BPS for assessment of the patients. In this first stage the most often evaluated were pain and disability, kinesiophobia and quality of life, and work-related factors. The intervention most used associate psychological and physical domains using pain education or cognitive functional therapy and active exercise. Even though was not the most common, in the social domain occupational, behavioral and family interventions were observed.

CONCLUSION

BPS is more often used as combination of physical and psychological aspects, being the social domain restricted to work-related factors. Patien'ts perception of their health status is little explored, and it is suggested that the International Classification of Functioning, Disability and Health be used.

PRACTICE IMPLICATION

Patient perception as well as social factors in addition to occupational ones should be included in the clinical approach of the patient with CLBP and should be further explored in research.

Combining various acupuncture therapies with multimodal analgesia to enhance postoperative pain management following total knee arthroplasty: a network meta-analysis of randomized controlled trials

OBJECTIVE

This study aims to evaluate the efficacy and safety of various acupuncture treatments in conjunction with multimodal analgesia (MA) for managing postoperative pain and improving knee function in patients undergoing total knee arthroplasty (TKA), based on the findings from clinical research indicating the potential benefits of acupuncture-related therapies in this context.

METHODS

We searched Web of Science, PubMed, SCI-hub, Embase, Cochrane Library, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), Wanfang Data, and Chinese Scientific Journal Database (VIP) to collect randomized controlled trials of acupuncture-related therapies for post-TKA pain. After independent screening and data extraction, the quality of the included literature was evaluated. The potential for bias in the studies incorporated in the analysis was assessed according to the guidelines outlined in the Cochrane Handbook 5.1. Network meta-analysis (NMA) was conducted using RevMan 5.4 and Stata 16.0 software, with primary outcome measures including visual analog scale (VAS), pain pressure threshold (PPT), hospital for special surgery knee score (HSS), and knee joint range of motion (ROM). Furthermore, the interventions were ranked based on the SUCRA value.

RESULTS

We conducted an analysis of 41 qualifying studies encompassing 3,003 patients, examining the efficacy of four acupuncture therapies (acupuncture ACU, electroacupuncture EA, transcutaneous electrical acupoint stimulation TEAS, and auricular acupoint therapy AAT) in conjunction with multimodal analgesia (MA) and MA alone. The VAS results showed no significant difference in efficacy among the five interventions for VAS-3 score. However, TEAS+MA (SMD: 0.67; 95%CI: 0.01, 1.32) was more effective than MA alone for VAS-7 score. There was no significant difference in PPT score among the three interventions. ACU + MA (SMD: 6.45; 95%CI: 3.30, 9.60), EA + MA (SMD: 4.89; 95%CI: 1.46, 8.32), and TEAS+MA (SMD: 5.31; 95%CI: 0.85, 9.78) were found to be more effective than MA alone for HSS score. For ROM score, ACU + MA was more efficacious than EA + MA, TEAS+MA, and AAT + MA, MA. Regarding the incidence of postoperative adverse reactions, nausea and vomiting were more prevalent after using only MA. Additionally, the incidence of postoperative dizziness and drowsiness following ACU + MA (OR = 4.98; 95%CI: 1.01, 24.42) was observed to be higher compared to that after AAT + MA intervention. Similarly, the occurrence of dizziness and drowsiness after MA was found to be significantly higher compared to the following interventions: TEAS+MA (OR = 0.36; 95%CI: 0.18, 0.70) and AAT + MA (OR = 0.20; 95%CI: 0.08, 0.50). The SUCRA ranking indicated that ACU + MA, EA + MA, TEAS+MA, and AAT + MA displayed superior SUCRA scores for each outcome index, respectively.

CONCLUSION

For the clinical treatment of post-TKA pain, acupuncture-related therapies can be selected as a complementary and alternative therapy. EA + MA and TEAS+MA demonstrate superior efficacy in alleviating postoperative pain among TKA patients. ACU + MA is the optimal choice for promoting postoperative knee joint function recovery in TKA patients. AAT + MA is recommended for preventing postoperative adverse reactions.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/, identifier (CRD42023492859).

Identifying priority gaps in contextual factors research and force-based manipulation. An international and interdisciplinary Delphi study

OBJECTIVE

To establish priority gaps related to contextual factors (CFs) research and force-based manipulation (FBM).

METHODS

A three-round Delphi following recommended guidelines for conducting and reporting Delphi studies (CREDES) involving international and interdisciplinary panelists with expertise in CFs and FBM. Round 1 was structured around two prompting questions created by the workgroup. Ranking of each priority gap was done by calculating composite scores for each theme generated. Consensus threshold was set with an agreement ≥75% among panelists. Median and interquartile range were calculated for each priority gap to provide the central tendency of responses. Wilcoxon rank-sum test was used to evaluate the consistency and stability of responses between rounds 2 and 3.

RESULTS

Forty-six panelists participated in all three rounds of the Delphi. Consensus was reached for 16 of 19 generated themes for priority gaps in CFs research and FBM. The ranking of each identified gap was computed and presented. Wilcoxon rank-sum test was non-significant (P > .05), demonstrating consistency and stability of results between rounds.

CONCLUSION

The result of this Delphi provides international and interdisciplinary consensus-based priority gaps in CFs research and FBM. The gaps identified can be used to generate future research inquiries involving CFs research and FBM.

Nurses' perspectives on user-friendly self-sampling interventions for diagnosis of sexually transmitted infections among young women in eThekwini district municipality: a nominal group technique

BACKGROUND

Syndromic management in the main non-laboratory-based management approach for sexually transmitted infections (STI) in most low- and middle-income countries (LMICs) but it has limitations. Self-sampling has been proven as a suitable alternative approach to help improve management STIs by improving access to diagnosis among vulnerable populations. We sought to determine health workers' perspectives on user-friendly self-sampling interventions for STIs among young women in eThekwini District Municipality.

METHODS

Healthcare workers providing STI healthcare services in the study location participated in a nominal group technique (NGT) workshop. The NGT workshop was aimed enabling collaboration with key health providers in identifying user-friendly self-sampling interventions for diagnosis of STIs among young women. Data collection was conducted in two phases: phase 1 determined barrier that hinder young women from accessing current STI healthcare services and phase 2 focused on determining the key strategies for self-sampling interventions to diagnose STIs in young women. Thematic analysis and percentage form analysis were used to examine qualitative and quantitative data respectively.

RESULTS

The following barriers were identified: negligence; myths about STIs; fear of judgement; denial; operating hours; lack of knowledge of STI symptoms and safe sex practices; and stigma associated with STIs. The following strategies were suggested: hand out self-sampling kits at popular restaurants; collect self-sampling kits from security guard at primary healthcare clinics (PHCs); receive STI diagnostic results via SMS or email or the clinic for treatment; improve youth friendly services at PHCs; educate the public on proper use of the kits. Education about STIs and handing out self-sampling kits at clinics, universities, schools, pharmacies or via outreach teams were ranked high priority strategies.

CONCLUSIONS

The findings highlight the need to address stigma and fear of judgment and provide comprehensive education to improve healthcare-seeking behaviour in young women. Additionally, the study also indicates that using eHealth solutions could significantly enhance the accessibility and efficiency of STI healthcare services in LMICs.

Distress in the care of people with chronic low back pain: insights from an ethnographic study

Introduction

Distress is part of the experiences and care for people with chronic low back pain. However, distress is often pathologised and individualised; it is seen as a problem within the individual in pain and something to be downplayed, avoided, or fixed. To that end, we situate distress as a normal everyday relational experience circulating, affecting, moving in, through, and across bodies. Challenging practices that may amplify distress, we draw on the theorisation of affect as a relational assemblage to analyse physiotherapy clinical encounters in the care of people with chronic low back pain.

Methods

Adopting a critical reflexive ethnographic approach, we analyse data from a qualitative project involving 15 ethnographic observations of patient-physiotherapist interactions and 6 collaborative dialogues between researchers and physiotherapists. We foreground conceptualisations of distress- and what they make (im)possible-to trace embodied assemblage formations and relationality when caring for people with chronic low back pain.

Results

Our findings indicate that conceptualisation matters to the clinical entanglement, particularly how distress is recognised and navigated. Our study highlights how distress is both a lived experience and an affective relation-that both the physiotherapist and people with chronic low back pain experience distress and can be affected by and affect each other within clinical encounters.

Discussion

Situated at the intersection of health sociology, sociology of emotions, and physiotherapy, our study offers a worked example of applying an affective assemblage theoretical framework to understanding emotionally imbued clinical interactions. Viewing physiotherapy care through an affective assemblage lens allows for recognising that life, pain, and distress are emerging, always in flux. Such an approach recognises that clinicians and patients experience distress; they are affected by and affect each other. It demands a more humanistic approach to care and helps move towards reconnecting the inseparable in clinical practice-emotion and reason, body and mind, carer and cared for.

Efficacy and safety of yoga for the management of chronic low back pain: an overview of systematic reviews

Background

Yoga is a non-pharmacological conservative therapeutic modality that can be employed for the management of chronic low back pain (CLBP). In this overview, we have summarized and evaluated data from current systematic reviews (SRs) on the use of yoga for CLBP.

Methods

We comprehensively searched SRs on the use of yoga for CLBP in nine electronic databases from inception to September 2023. The methodological quality was evaluated using the Assessment of Multiple Systematic Review Scale-2 (AMSTAR-2). The reporting quality of the included SRs was evaluated using the Preferred Reporting Item for Systematic Review and Meta-Analysis-2020 (PRISMA-2020), and the quality of data was graded using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Two independent researchers performed the screening, data extraction, and quality assessment process of SRs.

Results

A total of 13 SRs were included. The results of the AMSTAR-2 indicated that the methodological quality of the included studies was relatively low. The PRISMA-2020 checklist evaluation results indicated that methodological limitations in reporting, especially regarding data processing and presentation, were the main weaknesses. The GRADE assessment indicated that 30 outcomes were rated moderate, 42 were rated low level, and 20 were rated very low level. Downgrading factors were mainly due to the limitations of the included studies.

Conclusion

Yoga appears to be an effective and safe non-pharmacological therapeutic modality for the Management of CLBP. Currently, it may exhibit better efficacy in improving pain and functional disability associated with CLBP. However, the methodological quality and quality of evidence for SRs/MAs in the included studies were generally low, and these results should be interpreted cautiously.