Exposure in Vivo as a Treatment Approach to Target Pain-Related Fear: Theory and New Insights From Research and Clinical Practice.

Pain-related fear (PRF) can be a significant factor contributing to the development and maintenance of pain-related disability in individuals with persistent pain. One treatment approach to target PRF and related avoidance behavior is exposure in vivo (EXP). EXP has a long history in the field of anxiety, a field that is constantly evolving. This Perspective outlines recent theoretical advancements and how they apply to EXP for PRF, including suggestions for how to optimize inhibitory learning during EXP; reviews mechanistic work from neuroimaging supporting the targeting of PRF in people with chronic pain; and focuses on clinical applications of EXP for PRF, as EXP is moving into new directions regarding who is receiving EXP (eg, EXP in chronic secondary pain) and how treatment is provided (EXP in primary care with a crucial role for physical therapists). Considerations are provided regarding challenges, remaining questions, and promising future perspectives. IMPACT: For patients with chronic pain who have elevated pain-related fear (PRF), exposure is the treatment of choice. This Perspective highlights the inhibitory learning approach, summarizes mechanistic work from experimental psychology and neuroimaging regarding PRF in chronic pain, and describes possible clinical applications of EXP in chronic secondary pain as well as in primary care.

Implementation of health education interventions at Dutch music schools.

A randomized controlled trial was conducted comparing the effects of a biopsychosocial course (PRESTO-Play) vs. physical activity promotion (PRESTO-Fit) to reduce disability related to musculoskeletal disorders in music students. The current study provides an external validation and a formative and process evaluation, allowing for a better interpretation of results. First, a group of experts was asked to complete a structured evaluation of design and content of the trial. Second, quantitative and qualitative data were analysed from different stakeholders (students, therapists and conservatory staff) using questionnaires, logs, field notes and emails to evaluate fidelity, dose delivered, dose received, reach and context. Results are presented descriptively. Two authors independently identified key responses that were merged into themes. Although no difference in disability was found between interventions, closer evaluation revealed that participants in PRESTO-Play reported that they learned about prevention of physical complaints and were more satisfied with course contents compared with PRESTO-Fit. Study design and contents of the interventions were found to be valid, with an appropriate dose delivered. Feedback from students and logs suggested that behavioural change and psychosocial principles in PRESTO-Play might have not been implemented optimally. Only moderate fidelity in both groups and too little contrast between interventions could have influenced results. Low attendance rates and a presumed lack of generalization further decreased possible effectiveness. Context greatly influenced implementation. Implementing a future health course with closer collaboration with the institution could optimize accessibility and communication, encourage attendance and enhance motivation for behavioural change.

Clinicians' Initial Experiences of Transition to Online Interdisciplinary Pain Rehabilitation During the Covid-19 Pandemic.

OBJECTIVE: Public health legislation during the CO-VID-19 pandemic has resulted in forced transitioning to the use of remote care in order to continue the provision of pain rehabilitation worldwide. The objective of this study was to gain insight into clinicians' initial experiences with the provision of interdisciplinary pain rehabilitation via videoconferencing. DESIGN: Observational, cross-sectional design. PARTICIPANTS: Twelve team members (specialists in rehabilitation medicine -MD-, psychologists, physiotherapists and occupational therapists) from a tertiary expertise centre in pain rehabilitation. METHODS: Quantitative and qualitative data were collected via a digital survey. Theme-based content analysis was performed for qualitative data. RESULTS: The themes that emerged were: the compulsory context; prerequisites for proper use of videoconferencing methods, which are strongly associated with the clinicians' experiences; changes experienced in specific components of pain rehabilitation; and overarching changes experienced, including opportunities and limitations (sub-themes: therapeutic relationship, system involvement, efficiency, hands-on possibilities, interdisciplinary teamwork, and formalities). Overall, clinicians expressed moderate agreement with the statements that the quality of the pain rehabilitation programme can be maintained using videoconferencing, and that the COVID-19 pandemic offers opportunities for growth and innovation in telehealth. CONCLUSION: It is feasible to provide valid and satisfactory pain rehabilitation via videoconferencing. This study identified facilitators and barriers to the use of videoconferencing, and great potential for integrating aspects of telehealth into standard care after the pandemic.

Health Education Literacy and Accessibility for Musicians: A Global Approach. Report from the Worldwide Universities Network Project.

OBJECTIVE: To address the need for accessible health education and improved health literacy for musicians throughout their lifespan. METHODS: Formation of a multicultural, international, and interdisciplinary collaborative research team, funded by the Worldwide Universities Network. The goal is to design a multi-strand research program to develop flexible and accessible approaches to health education for musicians, thus improving their health literacy. RESULTS: Two team meetings took place in 2018. The first was held 11 to 15 April 2018 in Perth, Australia, and involved a review of existing literature and interventions on health education in music schools, intensive development of research topics, aims, and methodologies, and identification of potential funding sources to support future large-scale research programs. This resulted in the draft design of three research projects, finalized during a second meeting in Maastricht, the Netherlands, 27 to 31 August 2018. DISCUSSION: These intensive meetings identified the need for both cultural change in music education settings as well as improved health literacy in musicians across global geographical regions. A global project to address health literacy and health education accessibility for musicians has commenced.

The Musician as (In)Active Athlete?: Exploring the Association Between Physical Activity and Musculoskeletal Complaints in Music Students.

OBJECTIVE: Musicians are often compared to athletes because of the physical exertion required to play music. The aim of this study was to explore the physical activity level of music students and to study its relationship with musculoskeletal complaints. A second goal was to assess associations between physical activity and pain, quality of life, and disability. METHODS: This cross-sectional study among third- and fourth-year music students used an electronic survey including measures for physical activity (SQUASH-Short Questionnaire to Assess Health-enhancing physical activity), musculoskeletal complaints (DMQ-Dutch Musculoskeletal Questionnaire), disability (DASH-Disability Arm, Shoulder, Hand questionnaire) and quality of life (Short Form-12). Students were classified as compliers or non-compliers with moderate- and vigorous-intensity physical activity recommendations. Statistical analysis was done using (non)parametric tests (t-test, Pearson chi-square test, Mann-Whitney U-test) and correlational testing. RESULTS: Participants were 132 students, 63.6% female, with a median age of 23 yrs (range 21.3-25.0). 67% reported musculoskeletal complaints in the past 7 days. Their median physical activity level was 6,390 MET-min/wk, and 62% and 10% of the students accomplished recommendations for moderate-intensity and vigorous-intensity physical activity levels, respectively. No significant differences were found in prevalence of musculoskeletal complaints between students who met moderate- or vigorous-intensity physical activity recommendations and students who did not. Physical activity level was not associated with musculoskeletal complaints (r=0.12, p=0.26). Higher pain intensity was associated with a lower quality of life (r=-0.53 p<0.01) and higher disability (r=0.43, p<0.01). CONCLUSIONS: Music students are mainly involved in light- to moderate-intensity physical activities and rarely in vigorous-intensity activities. No correlation was found between physical activity level in the past months and musculoskeletal complaints in music students.

PREvention STudy On preventing or reducing disability from musculoskeletal complaints in music school students (PRESTO): protocol of a randomised controlled trial.

INTRODUCTION: Up to 87% of professional musicians develop work-related complaints of the musculoskeletal system during their careers. Music school students are at specific risk for developing musculoskeletal complaints and disabilities. This study aims to evaluate the effectiveness of a biopsychosocial prevention program to prevent or reduce disabilities from playing-related musculoskeletal disorders. Secondary objectives are evaluation of cost-effectiveness and feasibility. METHODS: Healthy, first or second year students (n=150) will be asked to participate in a multicentre, single-blinded, parallel-group randomised controlled trial. Students randomised to the intervention group (n=75) will participate in a biopsychosocial prevention program that addresses playing-related health problems and provides postural training according to the Mensendieck or Cesar methods of postural exercise therapy, while incorporating aspects from behavioural change theories. A control group (n=75) will participate in a program that stimulates a healthy physical activity level using a pedometer, which conforms to international recommendations. No long-term effects are expected from this control intervention. Total follow-up duration is two years. The primary outcome measure is disability (Disabilities of Arm, Shoulder and Hand questionnaire). The secondary outcome measures are pain, quality of life and changes in health behaviour. Multilevel mixed-effect logistic or linear regression analyses will be performed to analyse the effects of the program on the aforementioned outcome measurements. Furthermore, cost-effectiveness, cost-utility and feasibility will be analysed. DISCUSSION: It is believed that this is the first comprehensive randomised controlled trial on the effect and rationale of a biopsychosocial prevention program for music students.

Energy expenditure in brass and woodwind instrumentalists: the effect of body posture.

OBJECTIVE: Body posture appears to influence fatigue and musculoskeletal complaints in musicians. Our aim was to determine energy expenditure and to investigate whether energy expenditure is affected by body posture in brass and woodwind instrumentalists. METHODS: Eighteen musicians (10 women, 8 men; 6 brass, 12 woodwinds), with a mean age of 39 ± 14 years and mean body mass index of 23.8 ± 4.9 kg/m², played their instruments for 30 minutes twice: once in nonoptimized body posture (posture A), and once in a posture according to the postural exercise therapy method Mensendieck (posture B). Patients were randomized to the order of postures in a crossover design AB/BA. Playing sessions were preceded and followed by 60 minutes of rest. Energy expenditure was measured in a respiration chamber with indirect calorimetry. Basal metabolic rate was measured with a ventilated hood. RESULTS: Mean metabolic equivalents (MET) for playing a wind instrument in the sitting position in a nonoptimized posture and posture according postural exercise therapy were 1.69 (SD 0.18) and 1.80 (SD 0.22), respectively. Percent change between resting metabolic rate and total energy expenditure while playing was 32% (95% CI 25-39%) in posture B and 23% (95% CI 17-30%) in posture A (p = 0.021). CONCLUSION: Average physical activity while playing a wind instrument approximates 1.8 MET. Our data show an association between energy expenditure and body posture while playing a brass or woodwind instrument: playing a musical instrument in a posture according to postural exercise therapy leads to higher energy expenditure as compared to a nonoptimized body posture. These results suggest that fatigue and the general feeling of lack of energy after playing a musical instrument are not related to actual higher energy expenditure.