Materials and methods: This study was a sub-analysis of a randomized controlled trial assessing whether the addition of Interactive Behavioral Modification Therapy (a cognitively informed physiotherapy treatment) to a Progressive Neck Exercise Program improved outcome in patients with chronic neck pain. Regression analyses were performed to determine the extent to which demographics, changes in pain, and changes in certain cognitive factors were related to changes in disability.
Results: In the progressive neck exercise group, changes in levels of pain intensity were the only factor significantly related to change in disability, explaining 33% of the variance. In the interactive behavioral modification therapy group, changes in pain intensity, and catastrophizing together explained 54% of the variance in change in disability. Only changes in catastrophizing displayed a significant β value in the final model.
Conclusions: Different processes appear to underpin changes in disability in patients undergoing cognitively informed physiotherapy to those undergoing a primarily exercise-based approach.
- Implications for rehabilitation
Certain cognitive factors are known to be related to levels of disability in patients with chronic neck pain
Specifically targeting these factors results in more patients making a clinically meaningful reduction in disability
Different processes appear to underpin reductions in disability when people with neck pain are treated with cognitively informed physiotherapy to when treated with exercise alone, which may account for why more patients improve when treated in this manner.
Reductions in catastrophizing appear to be particularly important and efforts should be made to assess and treat catastrophic thoughts in people with chronic neck pain.
Design: Qualitative study using semi-structured interviews in either a home or hospital setting.
Methods: Semi-structured interviews were conducted on eight participants attending hospital-based pain management. Participants were asked about their experiences of pain management and living with a chronic pain condition. Interviews were transcribed and analysed thematically.
Results: Three main themes were identified; impact of their condition on daily life, clinical interactions and the pain management process. Understanding the condition was a key factor for the patients, in particular, explanation by the clinician. The temporality of their pain meant timing of appointments was critical. Patients reported factors such as family days and follow-up sessions would improve their treatment experience.
Conclusions: This study highlighted important factors for healthcare professionals and patients in the management of chronic pain. Participants indicated a desire to understand their condition and learn strategies for self-management to allow them to cope better. As patients found benefit from being involved in the management process, discussions around the options for treatment may enhance management and rehabilitation. It is important we continue to research factors important to individuals with musculoskeletal pain to find an effective, evidence-based framework for understanding and managing this condition.
- Implications for rehabilitation
This study highlights the importance to patients of being given information to help them understand their pain condition and to learn strategies for self-management to cope better.
Where information was not provided and inadequate time allowed for questioning and discussion, patients tended to desire more frequent access to the care services. More effective communication may result in reduced demand and more efficient management.
Patients suggested that ongoing peer support may offer an alternative to clinician-led services.
Methods: Studies whose primary goal was to evaluate the effectiveness of repetitive magnetic stimulation for the treatment of various types of neuropathic pain published in PubMed until August 2015 have been included in this systematic review.
Results: A total of 39 articles fulfilling the inclusion criteria were analyzed of which 37 studies investigated pain modulation using repetitive magnetic stimulation over the motor or non-motor cortices and two studies evaluated pain modulation using repetitive peripheral magnetic stimulation protocols.
Conclusions: Repetitive transcranial magnetic stimulation of the primary motor cortex using high frequency stimulation protocols can effectively reduce neuropathic pain, particularly in individuals with pain related to non-cerebral lesions. The application of multiple sessions can lead to long-lasting pain modulation and cumulative effects.
- Implications for Rehabilitation
Maladaptive plasticity plays a central role in sensitization of nociceptive pathways, generation and maintainance of neuropathic pain;
Most neuropathic pain conditions are refractory to pharmacological therapies;
Repetitive magnetic stimulation of the central and peripheral nervous system has gained relevance as noninvasive approach for neuromodulation and pain relief.
Material and method: Qualitative interviews were used to uncover expectations about a multimodal rehabilitation programme offered at the Pain and Rehabilitations Centre, The University Hospital; Linköping, Sweden. Sixteen women and two men (mean age 37 years; standard deviation 10 years) with chronic benign pain participated. The interviews were analysed using qualitative content analyses.
Results: To participate actively in the multimodal pain rehabilitation programme and to learn adequate coping strategies to improve daily life emerged as a main category. It was based on the following four categories comprising expectations about: participating actively in the programme, interacting with the professionals and fellow patients, cognitive effects of the programme and tools for coping, and explicit effects from the programme.
Conclusions: Many patients expressed expectations which may reflect that the information before the programme had started rehabilitation process at the time point for this study. The results could be applied in rehabilitation programmes by acknowledging expectations to interact with professional team members and fellow patients, by early addressing of positive and negative expectations about the future pain and by incorporating and strengthen expectations of learning to cope with pain.
- Implications for Rehabilitation
Patients' expectations to interact with professional team members and fellow patients by participating actively in the pain rehabilitation programme should be acknowledged in each rehabilitation situation.
Patients expressed both positive and negative expectations about their future pain situation and these expectations should be addressed as early as possible in the rehabilitation screening process.
Patients' expectations of learning to cope with pain should be incorporated and strengthened in multimodal pain rehabilitation programmes.
Methods: Seven pwMS with varied demographic and disease characteristics completed the 8-week home-based program alongside 3 hours of telephone support. Online questionnaires were completed every four days for 16 weeks (4-weeks baseline, 8-weeks treatment, 4-weeks follow-up). The primary outcomes were pain severity and pain interference. Psychological process variables drawn from the MS pain model were also completed, and post-treatment qualitative interviews conducted.
Results: Simulation modeling analysis (SMA) showed three patients had large improvements in pain outcomes, two showed no change and two worsened. Five participants showed significant change on various psychological process variables. Change in pain catastrophizing was the most consistent finding.
Conclusions: The findings suggest a self-management program for MS pain with minimal therapy support may be effective for some pwMS, but not those with more complex comorbidities. The participants suggested web-based delivery may simplify the approach, and therapist telephone contact was highly valued.
- Implications for Rehabilitation
This case series suggests a hybrid CBT/ACT self-management workbook program for MS pain improves severity and impact of pain in some pwMS.
Pain-related catastrophizing reduced in most pwMS, whilst change in other ACT and CBT process variables varied across the individuals.
PwMS feedback suggests a tailored web-based delivery of the program with therapist telephone support may be optimal.
PwMS with serious co-morbid depression and very advanced disease may not respond well to this self-management approach.
Methods: This is a cross-sectional cohort study of 585 consecutive patients with chronic neck pain seen in a university hospital rehabilitation clinic. Internal consistency was evaluated using Cronbach’s alpha, construct structure was evaluated by exploratory factor analysis, and discrimination ability was determined by Item Response Theory.
Results: The NDI demonstrated good internal consistency assessed by Cronbach’s alpha (0.87). The exploratory factor analysis identified only one factor with eigenvalue considered significant (cutoff 1.0). When analyzed by Item Response Theory, eight out of 10 items demonstrated almost ideal difficulty parameter estimates. In addition, eight out of 10 items showed high to perfect estimates of discrimination ability (overall range 0.8 to 2.9).
Conclusions: Amongst patients with chronic neck pain, the NDI was found to have good internal consistency, have unidimensional properties, and an excellent ability to distinguish patients with different levels of perceived disability.
- Implications for Rehabilitation
The Neck Disability Index has good internal consistency, unidimensional properties, and an excellent ability to distinguish patients with different levels of perceived disability.
The Neck Disability Index is recommended for use when selecting patients for rehabilitation, setting rehabilitation goals, and measuring the outcome of intervention.
Materials and methods: Narrative review.
Results: First, pain education is an effective but underused strategy for treating cancer related pain. Second, our neuro-immunological understanding of how stress can influence pain highlights the importance of integrating stress management into the rehabilitation approach for patients having cancer-related pain. The latter is supported by studies that have examined the effectiveness of various stress management programmes in this population. Third, poor sleep is common and linked to pain in patients following cancer treatment. Sleep deprivation results in a low-grade inflammatory response and consequent increased sensitivity to pain. Cognitive behavioural therapy for sleep difficulties, stress management and exercise therapy improves sleep in patients following cancer treatment. Finally, exercise therapy is effective for decreasing pain in patients following cancer treatment, and may even decrease pain-related side effects of hormone treatments commonly used in cancer survivors.
Conclusions: Neuro-immunology has increased our understanding of pain and can benefit conservative pain treatment for adults following cancer treatment.
- Implications for Rehabilitation
Pain education is effective for improving cancer pain; implementation of contemporary pain neuroscience into the educational programme seems warranted.
Various types of stress management are effective for treating patients following cancer treatment.
Poor sleep is common in patients following cancer treatment, and rehabilitation specialists can address this by providing exercise therapy, sleep hygiene, and/or cognitive behavioural therapy.
Exercise therapy is effective for decreasing pain in patients following cancer treatment, including the treatment of pain as a common side effect of hormone treatments for breast cancer survivors.
Materials and methods: The data were obtained from 360 patients with rheumatic diseases who completed self-report measures assessing study variables. Structural equation modeling was used to examine the hypothesized relationships among factors specified in the fear-avoidance model predicting physical and psychological quality of life.
Results: Final models fit the data well, explaining 96% and 82% of the variance in physical and psychological quality of life, respectively. Higher pain catastrophizing was related to stronger fear-avoidance beliefs that had a direct negative association with physical disability and depression, which, in turn, negatively affected physical quality of life. Pain severity was also directly related to physical disability. Physical disability also affected physical quality of life indirectly through depression. The hypothesized relationships specified in the model were also confirmed for psychological quality of life. However, physical disability had an indirect association with psychological quality of life via depression.
Conclusion: The current results underscore the significant role of cognitive, affective, and behavioral factors in perceived physical disability and their mediated detrimental effect on physical and psychological quality of life in patients with rheumatic diseases.
- Implications for rehabilitation
The fear-avoidance model is applicable to the prediction of quality of life in patients with rheumatic diseases.
As pain-catastrophizing and fear-avoidance beliefs are important factors linked to physical disability and depression, intervening these cognitive factors is necessary to improve physical function and depression in patients with rheumatic diseases.
Considering the strong association between depression and physical and psychological quality of life, the assessment and treatment of the former should be included in the rehabilitation of patients with rheumatic diseases.
Interventions targeting physical function and depression are likely to be effective in terms of improving physical and psychological quality of life in patients with rheumatic diseases.
Method: The data from 27 interviews, conducted with 9 participants, was analyzed using the Empirical Phenomenological Psychological method.
Results: Work remained central to the lives of the participants and aligned with previous valued work outcomes and goals regardless of the amount of time away from work. These findings point to the importance of recognizing the ongoing centrality of work for those with chronic work disability and the importance of tapping into work values and beliefs to provide workers with the motivation needed to get past physical and systemic barriers to return to work.
Conclusions: This study shows that a shift in focus back to meaning not only has benefits for people with chronic work disability, but for occupational therapists in their ability to make a unique and effective contribution to the field of work disability.
- Implications for rehabilitation
The chronic work disabled population remains one of the most challenging to return to work.
Reflection on the meaning of work provides motivation needed for clients to overcome barriers to work including chronic pain.
Exploring meaning is not difficult or time consuming in vocational rehabilitation.
Materials and methods: Observational data on group climate and individual participation were triangulated with qualitative data from focus group interviews on the participants’ experiences with transdiagnostic groups.
Results: The study included 222 participants receiving a temporary work disability benefit. Self-reported chronic pain (75%), chronic fatigue (79%), and mental distress (62%) were prevalent and the majority reported overlapping conditions (78%). Program completion among participants was high (96%). Those completing participated actively (95%) in the program. Overall group climate was stable with moderately high engagement. Participants with clinically confirmed mental disorders (22%) showed similar outcomes. Self-reported problems with “working in a group” prior to rehabilitation were not associated with how participants experienced group climate. Qualitative data supported the findings of positive participant experiences with transdiagnostic group settings.
Conclusions: Transdiagnostic groups showed high participation rates, moderately high group engagement across symptom profiles and positive participant experiences. Implementing transdiagnostic occupational rehabilitation in groups mixing participants with chronic pain, chronic fatigue and common mental disorders was feasible and acceptable to participants.
- Implications for rehabilitation
Most research has been done on disorder-specific occupational rehabilitation programs, but emerging evidence supports a more generic approach.
Transdiagnostic therapies, such as Acceptance and Commitment Therapy (ACT), have shown promising results for both somatic and mental disorders.
The feasibility of implementing transdiagnostic rehabilitation groups, their acceptability to participants and the demand for such groups has not been established.
This study indicates that it is feasible to introduce a novel transdiagnostic group-based occupational rehabilitation program for mixed groups of sick-listed participants with chronic pain, chronic fatigue and/or common mental disorders.
Method: Patients with a diagnosis of NC and/or lumbar spinal stenosis were recruited through a UK NHS tertiary care center. Semi-structured interviews and self-report questionnaires were used to obtain data. A thematic analysis was conducted.
Results: 15 participants were recruited; half were classed as frail older adults. Pain and the threat of pain was a prominent feature of participants’ experience of NC. This led to a loss of engagement in meaningful activities and sense of self. Discourses of ageing influenced experiences as well as treatment preferences, particularly the acceptability of walking aids. A combination of one-to-one and group setting for treatment was preferred. Outcome preferences related to re-engagement in meaningful activities and pain reduction. Limitations relate to generalisability of the findings for NC patients not under physiotherapy treatment.
Conclusion: We have obtained important findings about older people’s experiences of living with NC and preferences for physiotherapy treatment and outcomes. These will be incorporated into an evidence-based intervention and evaluated in a randomized controlled trial.
- Implications for rehabilitation
Older people living with NC want to get back to meaningful activities and learn how to live with the threat of pain.
Allied health professionals (AHPs) should be sensitive to the complex and ambiguous ways in which older people live with ageing and age-related decline.
AHPs are in a position to support patients’ successful transition to the use of walking aids thereby reducing stigmatizing effects and increasing activity.
AHPs should consider a mixture of one-to-one and group classes to enable rehabilitation for older NC patients.
Methods: Participants in MMR from an outpatient rehabilitation unit in primary care in Sweden were recruited for interviews about any kind of change they experienced that they thought were related to their participation in the MMR. Systematic text condensation according to Malterud was used to analyze the data.
Results: A total of 14 participants were interviewed. The interview analysis resulted in four categories in which the participants described their experience of change related to the MMR: a new desire for participation, increased embodied knowledge, a stronger sense of feeling empowered and regained hope. The categories interacted and from these categories, one theme emerged: a sense of increased living space.
Conclusion: According to these results, it is important to have various entrances to enhance change and to be aware of how these changes interact and can reinforce each other in order to facilitate the participants’ empowerment processes toward a sense of increased living space.
- Implications for rehabilitation
The efforts in MMR should be coordinated to be mutually reinforcing as changes in one area could facilitate in others and thus facilitate the participants’ empowerment processes.
Participants experience change after MMR in areas that standardized assessment questionnaires do not capture and consequently it would be useful to let the participants answer an open question about perceived changes together with standardized questionnaires.
Methods: Sixty-six patients with persistent pain following musculoskeletal injury participated in this study. All participants were enrolled in a standardized multidisciplinary rehabilitation programme. Participants completed self-report measures of perceived injustice, pain intensity, disability, anger intensity and regulation style, depressive symptoms, and a measure of the working alliance with their principal rehabilitation clinician. Each participant’s principal clinician also completed the working alliance measure.
Results: Greater perceptions of injustice were associated with poorer client ratings of the working alliance. Results also showed that anger expression mediated the association between perceived injustice and the working alliance.
Conclusion: Strategies to enhance the working alliance between rehabilitation professionals and clients with elevated levels of perceived injustice are needed.
- Implications for Rehabilitation
Perceived injustice is associated with poor progress in rehabilitation programmes for people with musculoskeletal pain following injury.
Perceived injustice is negatively associated with the quality of the therapeutic working alliance.
Strategies to enhance the working alliance between rehabilitation professionals and clients with elevated levels of perceived injustice are needed.
Methods: Extensive research was performed in MEDLINE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Embase, Physiotherapy Evidence Database (PEDro) and Cochrane Central Register of Controlled Trials (CENTRAL) databases from their inception to September 2014. Potentially relevant articles were also manually looked for in the reference lists of the identified publications. Studies examining lumbar muscle fatigue in people with CNSLBP were selected. Two reviewers independently selected the articles, carried out the study quality assessment and extracted the results. A modified Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) scale was used to evaluate the scientific rigour of the selected works.
Results: Twenty-four studies fulfilled the selection criteria and were included in the systematic review. We found conflicting data regarding the validity of methods used to examine back muscle fatigue. The Biering-Sorensen test, performed in conjunction with surface electromyography spectral analysis, turned out to be the most widely used and comparatively, the most optimal modality currently available to assess objective back muscle fatigue in daily clinical practise, even though critical limitations are discussed.
Conclusions: Future research should address the identification of an advanced method for lower back fatigue assessment in patients with CNSLBP which, eventually, might provide physical therapists with an objective and reliable test usable in everyday clinical practise.
- Implications for Rehabilitation
Despite its limitations, the Biering-Sorensen test is currently the most used, convenient and easily available fatiguing test for lumbar muscles.
To increase validity and reliability of the Biering-Sorensen test, concomitant activation of synergistic muscles should be taken into account.
Pooled mean frequency and half-width of the spectrum are currently the most valid electromyographic parameters to assess fatigue in chronic non-specific low back pain.
Body mass index, grading of pain and level of disability of the study population should be reported to enhance research quality.
Materials and methods: Five series of neck muscle vibration were delivered to 15 neck pain patients and 11 healthy controls in this case control study. Outcomes were cervical joint position sense, arm-matching acuity, and pressure pain threshold at the zygapophyseal joint of C2/C3, the angulus superior, and the tibialis anterior muscle.
Results: Cervical joint position sense acuity improved in neck pain patients and declined in healthy controls even after 24?h. Arm-matching acuity improved in patients assessed after 15?min, as was pressure pain threshold at the angulus superior in neck pain patients. In contrast, changes in the pressure pain threshold at the tibia were only observable immediately after vibration.
Conclusion: Neck muscle vibration induced short-lasting general as well as longer-lasting specific effects on analgesia and sensorimotor function. Based on our observations, future studies should investigate potential benefits of neck muscle vibration as adjunct to physical therapy in order to improve cervical sensorimotor function.
- Implications for Rehabilitation
A single session of neck muscle vibration improves cervical joint position sense in neck patients for up to 24?h.
Neck muscle vibration improves arm-matching acuity in neck pain patients.
Neck muscle vibration increases pressure pain thresholds at the stimulated place but decrease pressure pain thresholds more distally.
Neck muscle vibration shows distinct effects in neck pain patients and healthy control.
Method: Cross-sectional study comparing HRQoL, measured by SF-36, among adults with UULD and an age- and gender-matched control group from the Norwegian general population (NGP).
Results: Seventy-seven respondents, median age 42 years (range: 20–82); 71% were women. Most had left-sided (61%), below elbow (53%), transverse (73%) deficiency. Compared to the NGP, the UULD group reported reduced HRQoL on all SF-36 subscales except for the role emotional (RE) scale (p=0.321), mental health (MH) (p=0.055) and mental component summary (MCS) (p=0.064). The greatest difference was on the bodily pain (BP) scale (point difference of 20.0). Multiple linear regression models showed significant association between several physical- and mental SF-36 subscales and occupational status, occurrence of comorbidity and chronic pain.
Conclusions: Persons with UULD reported reduced HRQoL on most SF-36 subscales, mostly in the physical health domain. Employment status, occurrence of comorbidity and chronic pain seem to have a negative impact on the HRQoL. Measures that can reduce pain and loss of function should be given particular attention in UULD rehabilitation.
- Implications for Rehabilitation
Persons with congenital unilateral upper limb deficiency (UULD) who experience pain and discomfort should seek professional help for evaluating their everyday coping strategies.
Professionals who meet persons with UULD should examine anomalies, comorbidity, pain and employment status before choosing advices and actions.
Individually adapted grip-improving devices, environments, physical exercise and pain management programs should be implemented early to reduce pain, loss of function and decreased HRQoL.
A multidisciplinary approach is often necessary when counseling persons with UULD.
Materials and methods: Fifteen patients with non-specific chronic pain from a transdisciplinary treatment centre were in-depth interviewed. Data collection and analysis were performed according to Grounded Theory.
Results: Five interacting topics emerged: (1) “the pre-Pain Neuroscience Education phase”, involving the primary needs to provide Pain Neuroscience Education, with subthemes containing (a) “a broad intake” and (b) “the healthcare professionals”; (2) “a comprehensible Pain Neuroscience Education” containing (a) “understandable explanation” and (b) “interaction between the physiotherapist and psychologist”; (3) “outcomes of Pain Neuroscience Education” including (a) “awareness”, b) “finding peace of mind”, and (c) “fewer symptoms”; 4) “"scepticism” containing (a) “doubt towards the diagnosis and Pain Neuroscience Education”, (b) “disagreement with the diagnosis and Pain Neuroscience Education”, and (c) “Pain Neuroscience Education can be confronting”.
Conclusion: This is the first study providing insight into the constructs contributing to the Pain Neuroscience Education experience of patients with non-specific chronic pain. The results reveal the importance of the therapeutic alliance between the patient and caregiver, taking time, listening, providing a clear explanation, and the possible outcomes when doing so. The findings from this study can be used to facilitate healthcare professionals in providing Pain Neuroscience Education to patients with non-specific chronic pain.
- Implications for Rehabilitation
An extensive biopsychosocial patient centred intake is crucial prior to providing Pain Neuroscience Education.
Repetitions of Pain Neuroscience Education, in different forms (verbal and written information, examples, drawings, etc.) help patients to understand the theory of neurophysiology.
Pain Neuroscience Education induces insight into the patient’s complaints, improved coping with complaints, improved self-control, and induces in some cases peace of mind.
Healthcare professionals providing Pain Neuroscience Education should be aware of the possible confronting nature of the contributing factors.