Background: Entry-level physiotherapy education in rheumatology is limited internationally, and o... more Background: Entry-level physiotherapy education in rheumatology is limited internationally, and our recent Australian research has demonstrated that even practising physiotherapists lack confidence in best-practice management of rheumatoid arthritis (RA). Given this situation and contemporary Australian arthritis models of care, we developed the innovative and interactive Rheumatoid Arthritis for Physiotherapists e-Learning (RAP-eL) web-based learning package. Purpose: The aims of this study were to
Results: There was an average 68% and 66% improvement in pain and ODI, respectively, between pre-... more Results: There was an average 68% and 66% improvement in pain and ODI, respectively, between pre-treatment and 24 months (p < 0.0001 for both comparisons). The maximum score of 5 on the Prolo scale was achieved in 63% and 22% of patients for economic and functional status, respectively. The global clinical success rate was 78% (39 of 50) based on no reoperations at the affected level due to persistent symptoms, a ≥2-point improvement in pain severity and a ≥15-point improvement in the ODI. Predictors of 24 month clinical success included discographic concordance (p < 0.0001), HIZ (p =0.0003), Pfirrmann grade (p =0.0002), and percent annulus coverage (p < 0.0001). There were no procedurerelated adverse events. Conclusions: The findings of this study suggest that durable clinical improvements can be realized after IDET in highly selected patients with mild disc degeneration, confirmatory imaging evidence of annular disruption and highly concordant pain provocation by low pressure discography.
IntroductionDespite the profound burden of disease, a strategic global response to optimise muscu... more IntroductionDespite the profound burden of disease, a strategic global response to optimise musculoskeletal (MSK) health and guide national-level health systems strengthening priorities remains absent. Auspiced by the Global Alliance for Musculoskeletal Health (G-MUSC), we aimed to empirically derive requisite priorities and components of a strategic response to guide global and national-level action on MSK health.MethodsDesign: mixed-methods, three-phase design.Phase 1: qualitative study with international key informants (KIs), including patient representatives and people with lived experience. KIs characterised the contemporary landscape for MSK health and priorities for a global strategic response.Phase 2: scoping review of national health policies to identify contemporary MSK policy trends and foci.Phase 3: informed by phases 1–2, was a global eDelphi where multisectoral panellists rated and iterated a framework of priorities and detailed components/actions.ResultsPhase 1: 31 KI...
Objectives Complex regional pain syndrome (CRPS) is a persistent pain condition which is often mi... more Objectives Complex regional pain syndrome (CRPS) is a persistent pain condition which is often misunderstood and poorly managed. Qualitative studies are needed to explore the lived experience of the condition and to better understand patient perspectives on their management experiences and needs. The aim of this study was to explore the lived experience of CRPS in Australia, including exploration of their perceptions of care and advice received from healthcare professionals. Methods A qualitative study with individual in-depth semi-structured, face-to-face interviews was performed (n=15, 80% female, average time elapsed since diagnosis 3.8 years). Qualitative data were analysed using an inductive thematic analysis approach. Results Four main themes with associated subthemes were identified, representing the participants’ journey: (1) Life Changing Impact of CRPS (Subthemes: Impact on self, Impact on others); (2) Variable Experiences of Care (Subthemes: Helpful experiences of care, U...
We welcome the recent review “Do we need a third mechanistic descriptor for chronic pain states?”... more We welcome the recent review “Do we need a third mechanistic descriptor for chronic pain states?” byKosek et al. and their invitation toexpand thisdiscussion to thewiderpaincommunity.Weareacutely aware of the need for internationally agreed pain terminology that is consistent, widely recognised, clinically useful, and allows for iteration as more research emerges regarding our understanding about pain. As Kosek et al. highlight, current approaches impose a binary classification between nociceptive pain and neuropathic pain. The authors also outline emergent issues associated with the recent redefinition of neuropathic pain by the IASP in 2011 and the associated clinical criteria for classifying neuropathic pain, leaving a substantial proportion of patients with pain unclassified. As clinical and research physiotherapists working with people with musculoskeletal pain and disability, we agree that this current binary system fails to acknowledge, or apply to, a sizeable subgroup of our clinical population. In clinical practice, this has many possible adverse consequences including: (1) inadequate recognition of patients whose pain cannot be classified within the current binary system; (2) less effective communication between clinicians and patients about the nature of their pain; (3) less informed consideration of treatment choices; and (4) potential for an unhelpful focus on peripheral tissue dysfunction to explain why pain persists. Kosek et al. suggested the following 3 proposals: (1) the assertion of nociceptive pain, (2) confirmation of the definition of neuropathic pain (but not as default), and (3) the need for a third mechanistic descriptor for people living with chronic pain that may serve to address some of the issues highlighted. With respect to items 1 and 2, we agree with current definitions and that pain classifications of nociceptive pain and neuropathic pain should not be dichotomous. With respect to item 3, we strongly support the arguments made for a third descriptor. It may be useful to note that some of us have previously published frameworks and models that attempt to address this issue and provide support for an expanded classification system of pain. As the topical review by Kosek et al. was positioned as a proposal welcoming debate, we would like to contribute by raising the following points: Point 1. The intention of the third descriptor described by Kosek et al. is “... to distinguish patients suffering from conditions where alterednociception hasbeendocumented from thosewhere thepain mechanisms are still truly unknown.” This raises the following issues: (1) While the focus in this review addresses chronic pain states, could the third descriptor also apply in acute pain states, given that abnormal functioning of the nociceptive system may also be apparent in some people with acute pain? (2) Pain “descriptors” in this classification systemmaynot necessarily be synonymous with the reasons for, or reflect all mechanisms underlying, ongoing pain, that is, there are multiple dimensions involved in characterising chronic pain, and descriptors may be helpful but only in the context of the whole clinical presentation. Therefore, classification of pain by descriptive terms is only one part of a broader framework for understanding the lived experience of pain, including psychosocial, lifestyle, genetics, and environmental factors that may contribute to sensitisation processes. How will a third descriptor (and requisite clinical criteria to satisfy the application of this descriptor) be acknowledged within a broader (biopsychosocial) framework? (3) Ideally, a third descriptor would not imply an algorithmic approach to care that focuses on the descriptor classifications alone or dominantly without considering this broader context. Perhaps, subsequent discussion could include how the addition of the third mechanistic descriptor be applied within the broader pain experience to guide treatment. Point 2. Information regarding what processes will be engaged to progress this proposal would bewelcome. Is this an IASP taxonomy committee task, and if so, how will the wider clinical and research community be engaged (eg, the use of a Delphi process, which could also capture perspectives on relevant clinical criteria that may characterise a third descriptor)? Previous research has adopted similar approaches to identify characteristics of centrally mediated pain in musculoskeletal conditions, yet further work is likely needed to develop broader consensus that has clinical applicability. We would welcome further discussion on this topic, and specifically the issues raised.
To explore the existence of subgroups in a cohort with chronic low back pain (n=294) based upon d... more To explore the existence of subgroups in a cohort with chronic low back pain (n=294) based upon data from multiple psychological questionnaires, and profile subgroups on data from multiple dimensions. Psychological questionnaires considered as indicator variables entered into latent class analysis included: Depression, Anxiety, Stress scales, Thought Suppression and Behavioural Endurance subscales (Avoidance Endurance questionnaire), Chronic Pain Acceptance questionnaire (short-form), Pain Catastrophising Scale, Pain Self-Efficacy questionnaire, and Fear-Avoidance Beliefs questionnaire. Multidimensional profiling of derived clusters included: demographics, pain characteristics, pain responses to movement, behaviors associated with pain, body perception, pain sensitivity, and health and lifestyle factors. Three clusters were derived. Cluster 1 (23.5%) was characterized by low cognitive and affective questionnaire scores, with the exception of fear-avoidance beliefs. Cluster 2 (58.8%)...
Background and aims Chronic low back pain (CLBP) is a complex disorder where central and peripher... more Background and aims Chronic low back pain (CLBP) is a complex disorder where central and peripheral nociceptive processes are influenced by factors from multiple dimensions associated with CLBP (e.g. movement, pain sensitivity, psychological). To date, outcomes for treatments matched to unidimensional subgroups (e.g. psychologically-based) have been poor. Therefore, unidimensional subgrouping may not reflect the complexity of CLBP presentations at an individual level. The aim of this study was therefore to explore patterns of classification at an individual level across the three previously-published, data-driven, within-dimension subgrouping studies. Methods Cross-sectional, multidimensional data was collected in 294 people with CLBP. Statistical derivation of subgroups within each of three clinically-important dimensions (pain sensitivity, psychological profile, pain responses following repeated spinal bending) was briefly reviewed. Patterns of classification membership were subse...
Background and aims There is high level evidence for physical activity (PA) improving outcomes in... more Background and aims There is high level evidence for physical activity (PA) improving outcomes in persistent pain disorders and one of the mechanisms proposed is the effect of exercise on central nociceptive modulation. Although laboratory studies and small field intervention studies suggest associations between physical activity and pain sensitivity, the association of objectively measured, habitual PA and sedentary behaviour (SB) with pain sensitivity requires further investigation. Current evidence suggests PA typically lowers pain sensitivity in people without pain or with single-site pain, whereas PA is frequently associated with an increase in pain sensitivity for those with multisite pain. The aim of this study was to explore the relationships of PA and SB with pain sensitivity measured by pressure pain thresholds and cold pain thresholds, considering the presence of single-site and multisite pain and controlling for potential confounders. Methods Participants from the Wester...
Background: Entry-level physiotherapy education in rheumatology is limited internationally, and o... more Background: Entry-level physiotherapy education in rheumatology is limited internationally, and our recent Australian research has demonstrated that even practising physiotherapists lack confidence in best-practice management of rheumatoid arthritis (RA). Given this situation and contemporary Australian arthritis models of care, we developed the innovative and interactive Rheumatoid Arthritis for Physiotherapists e-Learning (RAP-eL) web-based learning package. Purpose: The aims of this study were to
Results: There was an average 68% and 66% improvement in pain and ODI, respectively, between pre-... more Results: There was an average 68% and 66% improvement in pain and ODI, respectively, between pre-treatment and 24 months (p < 0.0001 for both comparisons). The maximum score of 5 on the Prolo scale was achieved in 63% and 22% of patients for economic and functional status, respectively. The global clinical success rate was 78% (39 of 50) based on no reoperations at the affected level due to persistent symptoms, a ≥2-point improvement in pain severity and a ≥15-point improvement in the ODI. Predictors of 24 month clinical success included discographic concordance (p < 0.0001), HIZ (p =0.0003), Pfirrmann grade (p =0.0002), and percent annulus coverage (p < 0.0001). There were no procedurerelated adverse events. Conclusions: The findings of this study suggest that durable clinical improvements can be realized after IDET in highly selected patients with mild disc degeneration, confirmatory imaging evidence of annular disruption and highly concordant pain provocation by low pressure discography.
IntroductionDespite the profound burden of disease, a strategic global response to optimise muscu... more IntroductionDespite the profound burden of disease, a strategic global response to optimise musculoskeletal (MSK) health and guide national-level health systems strengthening priorities remains absent. Auspiced by the Global Alliance for Musculoskeletal Health (G-MUSC), we aimed to empirically derive requisite priorities and components of a strategic response to guide global and national-level action on MSK health.MethodsDesign: mixed-methods, three-phase design.Phase 1: qualitative study with international key informants (KIs), including patient representatives and people with lived experience. KIs characterised the contemporary landscape for MSK health and priorities for a global strategic response.Phase 2: scoping review of national health policies to identify contemporary MSK policy trends and foci.Phase 3: informed by phases 1–2, was a global eDelphi where multisectoral panellists rated and iterated a framework of priorities and detailed components/actions.ResultsPhase 1: 31 KI...
Objectives Complex regional pain syndrome (CRPS) is a persistent pain condition which is often mi... more Objectives Complex regional pain syndrome (CRPS) is a persistent pain condition which is often misunderstood and poorly managed. Qualitative studies are needed to explore the lived experience of the condition and to better understand patient perspectives on their management experiences and needs. The aim of this study was to explore the lived experience of CRPS in Australia, including exploration of their perceptions of care and advice received from healthcare professionals. Methods A qualitative study with individual in-depth semi-structured, face-to-face interviews was performed (n=15, 80% female, average time elapsed since diagnosis 3.8 years). Qualitative data were analysed using an inductive thematic analysis approach. Results Four main themes with associated subthemes were identified, representing the participants’ journey: (1) Life Changing Impact of CRPS (Subthemes: Impact on self, Impact on others); (2) Variable Experiences of Care (Subthemes: Helpful experiences of care, U...
We welcome the recent review “Do we need a third mechanistic descriptor for chronic pain states?”... more We welcome the recent review “Do we need a third mechanistic descriptor for chronic pain states?” byKosek et al. and their invitation toexpand thisdiscussion to thewiderpaincommunity.Weareacutely aware of the need for internationally agreed pain terminology that is consistent, widely recognised, clinically useful, and allows for iteration as more research emerges regarding our understanding about pain. As Kosek et al. highlight, current approaches impose a binary classification between nociceptive pain and neuropathic pain. The authors also outline emergent issues associated with the recent redefinition of neuropathic pain by the IASP in 2011 and the associated clinical criteria for classifying neuropathic pain, leaving a substantial proportion of patients with pain unclassified. As clinical and research physiotherapists working with people with musculoskeletal pain and disability, we agree that this current binary system fails to acknowledge, or apply to, a sizeable subgroup of our clinical population. In clinical practice, this has many possible adverse consequences including: (1) inadequate recognition of patients whose pain cannot be classified within the current binary system; (2) less effective communication between clinicians and patients about the nature of their pain; (3) less informed consideration of treatment choices; and (4) potential for an unhelpful focus on peripheral tissue dysfunction to explain why pain persists. Kosek et al. suggested the following 3 proposals: (1) the assertion of nociceptive pain, (2) confirmation of the definition of neuropathic pain (but not as default), and (3) the need for a third mechanistic descriptor for people living with chronic pain that may serve to address some of the issues highlighted. With respect to items 1 and 2, we agree with current definitions and that pain classifications of nociceptive pain and neuropathic pain should not be dichotomous. With respect to item 3, we strongly support the arguments made for a third descriptor. It may be useful to note that some of us have previously published frameworks and models that attempt to address this issue and provide support for an expanded classification system of pain. As the topical review by Kosek et al. was positioned as a proposal welcoming debate, we would like to contribute by raising the following points: Point 1. The intention of the third descriptor described by Kosek et al. is “... to distinguish patients suffering from conditions where alterednociception hasbeendocumented from thosewhere thepain mechanisms are still truly unknown.” This raises the following issues: (1) While the focus in this review addresses chronic pain states, could the third descriptor also apply in acute pain states, given that abnormal functioning of the nociceptive system may also be apparent in some people with acute pain? (2) Pain “descriptors” in this classification systemmaynot necessarily be synonymous with the reasons for, or reflect all mechanisms underlying, ongoing pain, that is, there are multiple dimensions involved in characterising chronic pain, and descriptors may be helpful but only in the context of the whole clinical presentation. Therefore, classification of pain by descriptive terms is only one part of a broader framework for understanding the lived experience of pain, including psychosocial, lifestyle, genetics, and environmental factors that may contribute to sensitisation processes. How will a third descriptor (and requisite clinical criteria to satisfy the application of this descriptor) be acknowledged within a broader (biopsychosocial) framework? (3) Ideally, a third descriptor would not imply an algorithmic approach to care that focuses on the descriptor classifications alone or dominantly without considering this broader context. Perhaps, subsequent discussion could include how the addition of the third mechanistic descriptor be applied within the broader pain experience to guide treatment. Point 2. Information regarding what processes will be engaged to progress this proposal would bewelcome. Is this an IASP taxonomy committee task, and if so, how will the wider clinical and research community be engaged (eg, the use of a Delphi process, which could also capture perspectives on relevant clinical criteria that may characterise a third descriptor)? Previous research has adopted similar approaches to identify characteristics of centrally mediated pain in musculoskeletal conditions, yet further work is likely needed to develop broader consensus that has clinical applicability. We would welcome further discussion on this topic, and specifically the issues raised.
To explore the existence of subgroups in a cohort with chronic low back pain (n=294) based upon d... more To explore the existence of subgroups in a cohort with chronic low back pain (n=294) based upon data from multiple psychological questionnaires, and profile subgroups on data from multiple dimensions. Psychological questionnaires considered as indicator variables entered into latent class analysis included: Depression, Anxiety, Stress scales, Thought Suppression and Behavioural Endurance subscales (Avoidance Endurance questionnaire), Chronic Pain Acceptance questionnaire (short-form), Pain Catastrophising Scale, Pain Self-Efficacy questionnaire, and Fear-Avoidance Beliefs questionnaire. Multidimensional profiling of derived clusters included: demographics, pain characteristics, pain responses to movement, behaviors associated with pain, body perception, pain sensitivity, and health and lifestyle factors. Three clusters were derived. Cluster 1 (23.5%) was characterized by low cognitive and affective questionnaire scores, with the exception of fear-avoidance beliefs. Cluster 2 (58.8%)...
Background and aims Chronic low back pain (CLBP) is a complex disorder where central and peripher... more Background and aims Chronic low back pain (CLBP) is a complex disorder where central and peripheral nociceptive processes are influenced by factors from multiple dimensions associated with CLBP (e.g. movement, pain sensitivity, psychological). To date, outcomes for treatments matched to unidimensional subgroups (e.g. psychologically-based) have been poor. Therefore, unidimensional subgrouping may not reflect the complexity of CLBP presentations at an individual level. The aim of this study was therefore to explore patterns of classification at an individual level across the three previously-published, data-driven, within-dimension subgrouping studies. Methods Cross-sectional, multidimensional data was collected in 294 people with CLBP. Statistical derivation of subgroups within each of three clinically-important dimensions (pain sensitivity, psychological profile, pain responses following repeated spinal bending) was briefly reviewed. Patterns of classification membership were subse...
Background and aims There is high level evidence for physical activity (PA) improving outcomes in... more Background and aims There is high level evidence for physical activity (PA) improving outcomes in persistent pain disorders and one of the mechanisms proposed is the effect of exercise on central nociceptive modulation. Although laboratory studies and small field intervention studies suggest associations between physical activity and pain sensitivity, the association of objectively measured, habitual PA and sedentary behaviour (SB) with pain sensitivity requires further investigation. Current evidence suggests PA typically lowers pain sensitivity in people without pain or with single-site pain, whereas PA is frequently associated with an increase in pain sensitivity for those with multisite pain. The aim of this study was to explore the relationships of PA and SB with pain sensitivity measured by pressure pain thresholds and cold pain thresholds, considering the presence of single-site and multisite pain and controlling for potential confounders. Methods Participants from the Wester...
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