Physiospot Pain

Central mechanisms in the maintenance of chronic widespread noninflammatory muscle pain.

Desantana JM, Sluka KA

This article reviews the current and emerging literature about the pathophysiology and neurobiology of chronic widespread -musculoskeletal pain. Widespread musculoskeletal pain results in changes in the central nervous system in human subjects and animal models. These changes likely reflect alterations in supraspinal modulation of nociception, and include increases in excitatory and decreases in inhibitory modulation pathways. These alterations in excitation and inhibition likely drive changes observed in the spinal cord to result in central sensitization, and the consequent pain and hyperalgesia.

Current Pain and Headache Reports, 2008, 12(5), 338-43

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Acute Opioid Administration Improves Work-Related Exercise Performance in Patients With Chronic Back Pain

Douglas P. Gross, Yagesh Bhambhani, Mark J. Haykowsky, Saifudin Rashiq

This study axamines the impact of acute opioid administration on work-related exercise performance in patients with chronic back pain. Subjects performed a continuous lifting and lowering test to voluntary fatigue at a load equivalent to 33% of their predetermined maximal lifting load twice: Once after receiving a single intravenous dose of 1 μg/kg fentanyl (a narcotic analgesic) and once after saline placebo.

This article presents the results of a clinical trial showing that acute opioid administration improves work-related exercise performance in individuals with chronic back pain. Longer trials of the effectiveness of opioid analgesia as an adjunct to functional restoration programs are recommended.

The Journal of Pain, 2008, 9(9), 856-862

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MACP/PPA Collaborative Study Day 2007 - Online Now!

The Manipulation Association of Chartered Physiotherapists (MACP) have released their first online course. It is an online version of the 2007 MACP/PPA collaborative study day and is very much an evidence-based programme where both manual therapy and pain based approaches to treatment were respected and represented. The online course includes audiovisual presentaions plus related learning activities using materials from the sessions that were presented at this study day and provides a course certificate on completion of the course.

 

Session 1 - The Evidence for Manual Therapy presented by Dries Hettinga
Session 2 -CBT: What is it and can physios do it? presented by Zara Hansen
Session 3 - Exercise: Making It Happen presented by Zara Hansen
Session 4 - The Physiology of Manual Therapy presented by Stephanie Griffiths.

Go to the online course

Massage Reduces Pain Perception and Hyperalgesia in Experimental Muscle Pain: A Randomized, Controlled Trial

Laura A. Frey Law, Stephanie Evans, Jill Knudtson, Steven Nus, Kerri Scholl, Kathleen A. Sluka

The purpose of this study was to evaluate the effects of massage on mechanical hyperalgesia and perceived pain using delayed onset muscle soreness as an endogenous model of myalgia. The participants (no-treatment control, superficial touch, or deep-tissue massage groups) performed eccentric wrist extension exercises at visit 1 to induce DOMS 48 hours later at visit 2. Pain, assessed using VAS and PPT were measured at baseline, after exercise, before treatment, and after treatment. Deep massage decreased pain during muscle stretch. Mechanical hyperalgesia was reduced after both the deep massage and superficial touch groups relative to control.

This randomized, controlled trial suggests that massage is capable of reducing myalgia symptoms by approximately 25% to 50%, varying with assessment technique. Thus, potential analgesia may depend on the pain assessment used. This information may assist clinicians in determining conservative treatment options for patients with myalgia.

The Journal of Pain, 9(8), 714-721

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Withdrawal of Analgesic Medication for Chronic Low-Back Pain Patients: Improvement in Outcomes of Multidisciplinary Rehabilitation Regardless of Surgical History.

Crisostomo, Ralph A; Schmidt, John E; Hooten, W Michael; Kerkvliet, Jennifer L; Townsend, Cynthia O; Bruce, Barbara K

The objective of this study was to determine the posttreatment outcomes of multidisciplinary pain rehabilitation that incorporates analgesic medication withdrawal for chronic low-back pain patients on the basis of lumbar spine surgical history.  In a retrospective analysis of 383 consecutive chronic low-back pain patients participating in a 3-wk, outpatient, intensive, multidisciplinary pain rehabilitation program: At admission, patients in both the fusion and nonfusion surgery groups were using more opioids compared with the no-surgery group. Reported pain severity and duration was highest in the fusion group compared with the other groups. Admission to dismissal comparisons showed significant and nearly equal improvements for all groups in health and medication measures.

Study results demonstrate that multidisciplinary pain rehabilitation treatment incorporating analgesic medication withdrawal is associated with significant clinical improvements in physical and emotional functioning, regardless of lumbar spine surgical history.

American Journal of Physical Medicine & Rehabilitation, 2008,    87(7), 527-536

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Do psychosocial factors predict disability and health at a 3-year follow-up for patients with non-acute musculoskeletal pain? A validation of the Örebro Musculoskeletal Pain Screening Questionnaire

A. Westman, S.J. Linton, J. Öhrvik, P. Wahlén and J. Leppert 

The aim of this study was to validate the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) for patients with non-acute pain problems and compare to other relevant questionnaires.  One hundred and fifty-eight patients with musculoskeletal pain and disability recruited to a multidisciplinary rehabilitation project completed a battery of questionnaires at baseline and at 3-year follow-up visits. The main analysis involved the relationship between risk levels in the questionnaire and sick leave and perceived health after 3 years.  The ÖMSPQ predicted future sick leave and health and was found to have six factors. The function and pain factors were the best predictors of sick leave after 3 years, while the distress factor was the best predictor of perceived mental health and return to work-expectancy was borderline significant. Perceived physical health at 3 years was best predicted by the function and pain factors with the fear-avoidance factor being marginally significant.

Psychosocial factors as measured by ÖMPSQ are related to work disability and perceived health even 3 years after treatment for patients with non-acute pain problems. The ÖMSPQ was a good predictor of outcome.

European Journal of Pain, 2008, 12(5), 641-649

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Mechanisms of pain referral in patients with whiplash associated disorder

Eva Kosek and Anna Januszewska 

The aim was to investigate the mechanisms of pain referral in patients with whiplash associated disorder. Pain was induced in 12 controls and 12 patients with whiplash associated disorder by intramuscular electrical stimulation in the infraspinatus muscle and the ipsilateral upper arm. Conditioning stimulation amounted to a pain intensity rated as 2/10 and 4/10. During conditioning stimulation in the infraspinatus muscle, sensitivity to test stimuli was assessed in the referred pain area (i.e., upper arm) and vice versa. Test stimuli consisted of intramuscular electrical stimulation corresponding to innocuous perception threshold, electrical pain threshold, and pain intensities rated as 2/10, 4/10 and 6/10, respectively. Compared to controls, patients with whiplash associated disorder had increased pain sensitivity and indicated larger areas of referred pain. During conditioning stimulation in the infraspinatus muscle all subjects reported referred pain in the upper arm and innocuous perception thresholds and electrical pain thresholds decreased. Conditioning stimulation in the upper arm did not affect sensitivity to test stimuli in the infraspinatus muscle. In conclusion this study found that patients with whiplash associated disorder had increased sensitivity to painful stimulation, reported larger areas of referred pain during the same subjectively painful conditioning stimulation, including proximal pain referral which was never seen in controls, indicating aberrant processing of nociceptive input. The perceptual integration of nociceptive stimuli during simultaneous stimulation did not differ between groups suggesting that divergence of nociceptive input from the focal pain area leading to excitation of neurones with projected fields in the referred pain area most likely explains referred pain in both groups alike.

European Journal of Pain, 2008, 12(5), 650-660

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Massage Reduces Pain Perception and Hyperalgesia in Experimental Muscle Pain: A Randomized, Controlled Trial

Laura A. Frey Law, Stephanie Evans, Jill Knudtson, Steven Nus, Kerri Scholl and Kathleen A. Sluka

The purpose of this study was to examine the effects of massage on mechanical hyperalgesia (pressure pain thresholds, PPT) and perceived pain using delayed onset muscle soreness (DOMS) as an endogenous model of myalgia. Participants were randomly assigned to a no-treatment control, superficial touch, or deep-tissue massage group. Eccentric wrist extension exercises were performed at visit 1 to induce DOMS 48 hours later at visit 2. Pain, assessed using visual analog scales (VAS), and PPTs were measured at baseline, after exercise, before treatment, and after treatment. Deep massage decreased pain (48.4% DOMS reversal) during muscle stretch. Mechanical hyperalgesia was reduced (27.5% reversal) after both the deep massage and superficial touch groups relative to control (increased hyperalgesia by 38.4%). Resting pain did not vary between treatment groups.

This randomized, controlled trial suggests that massage is capable of reducing myalgia symptoms by approximately 25% to 50%, varying with assessment technique. Thus, potential analgesia may depend on the pain assessment used. This information may assist clinicians in determining conservative treatment options for patients with myalgia.

The Journal of Pain, 2 May 2008, online article ahead of press

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Thinking about movement hurts: The effect of motor imagery on pain and swelling in people with chronic arm pain

Lorimer Moseley, Nadia Zalucki, Frank Birklein, Johan Marinus, Jacobus J. van Hilten, Hannu Luomajoki

This study investigated whether motor imagery, in the absence of movement, increases symptoms in patients with chronic arm pain. Pain and swelling were measured before, after, and 60 minutes after 37 subjects performed a motor imagery task. Secondary variables from clinical, psychophysical, and cognitive domains were related to change in symptoms using linear regression.  Motor imagery increased pain and swelling.  Increased pain and swelling related positively to duration of symptoms and performance on a left/right judgement task that interrogated the body schema, autonomic response, catastrophic thoughts about pain, and fear of movement. 

Motor imagery increased pain and swelling in patients with chronic painful disease of the arm. The effect increased in line with the duration of symptoms and seems to be modulated by autonomic arousal and beliefs about pain and movement. The results highlight the contribution of cortical mechanisms to pain on movement, which has implications for treatment.

Arthritis & Care Research, 2008, 59(5), 623-31

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Treatment Expectancy and Credibility Are Associated With the Outcome of Both Physical and Cognitive-behavioral Treatment in Chronic Low Back Pain.

Smeets, Rob J. E. M.; Beelen, Saskia; Goossens, Marielle E. J. B.; Schouten, Erik G. W.; Knottnerus, J. Andre; Vlaeyen, Johan W. S.

The objectives of this study were (1) to investigate the factor structure of the Credibility/Expectancy Questionnaire (CEQ) in a sample of chronic low back pain (CLBP) patients by means of a confirmatory factor analysis, (2) to examine the association between treatment credibility and expectancy and patient characteristics, and (3) to assess whether treatment expectancy and credibility are associated with the outcome of rehabilitation treatment.  CLBP patients were randomized to either active physical therapy, cognitive-behavioral therapy, or a combination therapy, and completed the CEQ after a careful explanation of the treatment rationale.

Although the associations found were low to modest, these results underscore the importance of expectancy and credibility for the outcome of different active interventions for CLBP and might contribute to the development of more effective treatments.

Clinical Journal of Pain, 24(4), 305-315

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