Gray Matter Adaptations to Chronic Pain in People with Whiplash-Associated Disorders are Partially Reversed After Treatment: A Voxel-based Morphometry Study.

Gray matter (GM) changes are often observed in people with chronic spinal pain, including those with chronic whiplash-associated disorders (CWAD). These GM adaptations may be reversed with treatment, at least partially. Pain neuroscience education combined with exercise (PNE+Exercise) is an effective treatment, but its neural underlying mechanisms still remain unexplored in CWAD. Here, we performed both cross-sectional and longitudinal voxel-based morphometry to 1) identify potential GM alterations in people with CWAD (n = 63) compared to age- and sex-matched pain-free controls (n = 32), and 2) determine whether these GM alterations might be reversed following PNE+Exercise (compared to conventional physiotherapy). The cross-sectional whole-brain analysis revealed that individuals with CWAD had less GM volume in the right and left dorsolateral prefrontal cortex and left inferior temporal gyrus which was, in turn, associated with higher pain vigilance. Fifty individuals with CWAD and 29 pain-free controls were retained in the longitudinal analysis. GM in the right dorsolateral prefrontal cortex increased after treatment in people with CWAD. Moreover, the longitudinal whole-brain analysis revealed that individuals with CWAD had decreases in GM volumes of the left and right central operculum and supramarginal after treatment. These changes were not specific to treatment modality and some were not observed in pain-free controls over time. Herewith, we provide the first evidence on how GM adaptations to CWAD respond to treatment. PERSPECTIVE: This article presents which gray matter adaptations are present in people with chronic pain after whiplash injuries. Then, we examine the treatment effect on these alterations as well as whether other neuroplastic effects on GM following treatment occur.

Use of Virtual Reality in Interdisciplinary Multimodal Pain Treatment With Insights From Health Care Professionals and Patients: Action Research Study.

BACKGROUND: Chronic pain is a widespread global health problem. Interdisciplinary multimodal pain treatment (IMPT) is a treatment option for people with chronic pain. Virtual reality (VR) could be used to broaden IMPT programs. However, despite the advantages of VR, it is rarely used in daily clinical practice. OBJECTIVE: This research aimed to explore how, when, and with whom VR can be used meaningfully during IMPT, either as an addition or substitution as a component of IMPT. METHODS: This research used an action research design to help health care professionals and patients learn how, when, and with whom they can use VR. Data were collected through reflection sessions with health care professionals and semistructured interviews with patients in 2 specialized centers that provide IMPT for chronic pain. Two researchers performed direct content analyses. RESULTS: In total, 4 physiotherapists, 1 occupational therapist, 3 psychologists, and 22 patients participated in this research. Three iteration cycles, including 9 reflection sessions and 8 semistructured interviews, were performed. Both health care professionals and patients considered VR to be useful in therapy as an addition but not a substitution. VR was used as a diagnostic and intervention tool with all patients at the rehabilitation center or home. VR was used to gain insight into patients' pain beliefs, cognitions, and irrational cognitions about additional damage and physical abilities. Considering VR as an intervention tool, the health care professionals had 3 goals: balancing relaxation and competition, grading activities, and exposure in vivo. CONCLUSIONS: VR could be a valuable addition to IMPT for both patients with chronic pain and health care professionals. More research should be performed to assess the additional effects of VR on patients' participation in daily life.

Disability and return to work after a multidisciplinary intervention for (sub)acute low back pain: A systematic review.

OBJECTIVE: This systematic review aimed to examine pain, functional status and return to work after a multidisciplinary intervention, with or without additional workplace intervention, for (sub)acute low back pain among adults. DATA SOURCES: A comprehensive search was completed (November 2022) in six electronic databases (Embase, MEDLINE, Web of Science, Cochrane, CENTRAL and Scopus) and in the reference list of all identified studies. REVIEW METHODS: The search results were screened against predefined eligibility criteria by two independent researchers. Included articles were systematic reviews or randomized controlled trials examining the effect of a multidisciplinary intervention, with or without workplace intervention, in working adults with (sub)acute low back pain. Relevant information was summarized and clustered, and the methodological quality and certainty of evidence were assessed respectively using the RoB 2-tool, the ROBIS tool and the GRADE criteria. RESULTS: The search resulted in a total of 3020 articles. After the screening process, 12 studies remained (11 randomized controlled trials and 1 systematic review), which studied overall 2751 patients, with a follow-up period of at least 12 months. CONCLUSIONS: A multidisciplinary intervention is favorable compared to usual care for pain intensity and functional status but this is less clear for return to work. Comparable work-related effects were found when comparing a multidisciplinary intervention with a less extensive intervention, whereas uncertainties exist regarding outcomes of pain intensity and functional status. Furthermore, adding a workplace intervention to usual care and subdividing patients based on work-related characteristics seems beneficial for return to work.

Temporal changes in pain processing after whiplash injury, based on Quantitative Sensory Testing: A systematic review.

BACKGROUND AND OBJECTIVE: After whiplash injury, some patients develop chronic whiplash-associated disorders. The exact pathophysiology of this chronification is still unclear and more knowledge is needed regarding the different post-injury phases. Therefore, studies were searched that examined temporal changes in pain processing, measured by Quantitative Sensory Testing (QST). DATABASES AND DATA TREATMENT: This systematic review searched three electronic databases (Medline, Web of Science and Embase) for articles meeting the eligibility requirements. Risk of bias was assessed according to a modified Newcastle-Ottawa Scale. RESULTS: The 12 included studies presented moderate to good methodological quality. These studies showed altered pain processing within the first month after injury and normalization within 3 months in 59%-78% of the patients. After 3 months, recovery stagnates during the following years. Thermal and widespread mechanical hyperalgesia occur already in the acute phase, but only in eventually non-recovered patients. CONCLUSIONS: Differences in pain processing between recovering and non-recovering patients can be observed already in the acute phase. Early screening for signs of altered pain processing can identify patients with high risk for chronification. These insights in temporal changes show the importance of rehabilitation in the acute phase. Future research should target to develop a standardized (bed-site) QST protocol and collect normative data which could, in relation with self-reported pain parameters, allow clinicians to identify the risk for chronification. SIGNIFICANCE: Altered pain processing is present soon after whiplash injury, but usually recovers within 3 months. Non-recovering patients show little to no improvements in the following years. Differences between recovering and non-recovering patients can be observed by Quantitative Sensory Testing already in the acute phase. Therefore, it is considered a feasible and effective tool that can contribute to the identification of high-risk patients and the prevention of chronification.

Consensus among musculoskeletal experts for the management of patients with headache by physiotherapists? A delphi study.

BACKGROUND: Though a large amount of research on the management of headache has been conducted, the clinical effectiveness of these treatments remains unclear. OBJECTIVES: To reach consensus among international musculoskeletal experts on what the most appropriate management is in patients that suffer from headache. DESIGN: Expert group and Delphi-study. METHODS: A total of 11 experts participated in the expert panel groups, where the role of physiotherapy in the management of headache was discussed. Afterwards, 14 of the initial 25 participants in the field of headache completed the whole Delphi study, which was conducted over 4 rounds. The first round aimed to identify clinical indicators and treatments that are useful in patients with headache. These questions were then categorized and ranked during the second, third, and fourth rounds. Consensual agreement was set at ≥ 80%. RESULTS: After the final round, 9 interventions were rated as useful by the participants. In the final extra round, 14 clinical indicators were retrieved as important to decide whether or not to start one of the consensual treatments. The top 3 management strategies were (1) upper cervical spine mobilisations in cervivogenic headache, (2) active mobilisation exercises of the cervical spine in cervivogenic headache, and (3) lifestyle advice in tension-type headache and migraine. CONCLUSION: International experts agreed that most scientifically established effective treatments are useful in cervicogenic headache. Consensual agreement on treatments for migraine and tension-type headache were only reached for specific treatments. Their recommendations provide a framework for further research and the clinical management of headache.