Microstructural changes in the median and ulnar nerve in people with and without diabetic neuropathy in their hands: A cross-sectional diffusion MRI study.

PURPOSE: Diffusion weighted imaging (DWI) has revealed microstructural changes in lower limb nerves in people with diabetic neuropathy. Microstructural changes in upper limb nerves using DWI in people with diabetes have not yet been explored. METHODS: This cross-sectional study aimed to quantify and compare the microstructure of the median and ulnar nerve in people without diabetes (n = 10), people with diabetes without distal symmetrical polyneuropathy (DSPN; n = 10), people with DSPN in the lower limbs only (DSPN FEET ONLY; n = 12), and people with DSPN in the upper and lower limbs (DSPN HANDS & FEET; n = 9). DSPN diagnosis included electrodiagnosis and corneal confocal microscopy. Tensor metrics, such as fractional anisotropy, radial diffusivity and axial diffusivity, and constrained spherical deconvolution metrics, such as dispersion and complexity, were calculated. Linear mixed-models were used to quantify DWI metrics from multiple models in median and ulnar nerves across the groups, and to evaluate potential differences in metrics at the wrist and elbow based on the principle of a distal-to-proximal disease progression. RESULTS: Tensor metrics revealed microstructural abnormalities in the median and ulnar nerve in people with DSPN HANDS & FEET, and also already in DSPN FEET ONLY. There were significant negative correlations between electrodiagnostic parameters and tensor metrics. A distal-to-proximal pattern was more pronounced in the median nerve. Non-tensor metrics showed early microstructural changes in people with diabetes without DSPN. CONCLUSION: Compared to people without diabetes, microstructural changes in upper limb nerves can be identified in people with diabetes with and without DSPN, even before symptoms occur.

A myriad of methods to determine temporal summation of pain in people with musculoskeletal pain and healthy participants: a scoping review.

Temporal summation of pain (TSP) is a human proxy for wind-up of dorsal horn neurons as assessed in animals. The common paradigm for eliciting TSP is evoked by repetitive nociceptive stimuli of equal intensity. Various stimulation and assessment protocols have been used. This scoping review aims to provide insight into key elements of TSP stimulation and assessment: modality, instruments, test location, familiarization, train characteristics, and calculations. PubMed, Embase, and Ebsco/CINAHL were searched for studies that measured TSP in adults with musculoskeletal conditions and healthy people. Four hundred six studies were included. Mechanical stimuli were the most commonly used modality (250 studies), followed by thermal stimuli (125 studies). Forty-six different instruments were used. Disregarding studies on widespread musculoskeletal pain and healthy participants, 40 studies evaluated TSP at painful sites, 77 in remote areas, and 66 in both locations. Of the 13 tested locations in patients, the hand (74 studies), lower leg (64 studies), and forearm (59 studies) were most commonly tested. A single practice round was the most common familiarization method (46 studies). Repeated stimuli were applied using 31 different frequencies (0.03-200 Hz) and sustained stimulations ranging from 5 to 1080 seconds were used. Twenty-two different train lengths, 63 different calculations (37 absolute, 19 relative, and 7 alternatives using data directly), and 14 different outcome measures (eg, self-reported pain rating scales and reflex thresholds) were used. Temporal summation of pain protocols vary excessively, hindering the comparison and pooling of results. None of the studies provided substantiation for their protocol choice.

The CROM-VAS Test: A novel and reliable clinical test to assess immediate pain relief following treatment for movement-evoked neck pain.

BACKGROUND: The CROM-VAS Test is a novel method to quantify immediate hypoalgesic treatment effects for neck pain by measuring the reduction in pain intensity (using a VAS) at the same (sub)maximal neck position (using a CROM device) before and after treatment. It is a novel test designed to quantify immediate pain relief following treatment, without the potentially confounding effects of simultaneous improvements in function. OBJECTIVES: (1) To describe the CROM-VAS Test, (2) To assess reliability and absolute agreement of the CROM-VAS Test, and (3) To evaluate its distinctiveness by comparing it to changes in pressure pain threshold (PPT) and baseline pain scores. DESIGN: Cross-sectional study. METHODS: The CROM-VAS Test was assessed in 58 people with non-specific neck pain treated with cervical mobilisation and cervicothoracic manipulation. Inter-rater reliability (intraclass correlation coefficient (ICC1.1)) and absolute agreement (standard error of measurement (SEM), minimal detectable change (MDC) and Bland-Altman limits of agreement (LoA)) were determined. RESULTS: Reliability was high (ICC1.1: 0.91 (95%CI: 0.85-0.95) for the CROM-VAS Test in the painful direction and 0.73 (95%CI: 0.54-0.85) in the non/least painful direction). Agreement was good (CROM-VAS Test (painful direction): SEM: 2.3 mm; MDC: 6.4 mm; LoA: 13.5 to 16.6 mm; CROM-VAS Test (non/least painful direction): SEM: 4.0 mm; MDC: 11.1 mm; LoA: 14.7 to 22.0 mm). Low or negative correlations were observed between CROM-VAS Test scores and changes in PPT and baseline neck pain scores. CONCLUSION: The CROM-VAS Test has good clinimetric properties. It measures a distinct dimension of pain relief compared to PPTs and baseline pain scores.

(Cost-)effectiveness of personalised multimodal physiotherapy compared to surgery in patients with cervical radiculopathy: A systematic review.

RATIONALE: Cervical radiculopathy is initially typically managed conservatively. Surgery is indicated when conservative management fails or with severe/progressive neurological signs. Personalised multimodal physiotherapy could be a promising conservative strategy. However, aggregated evidence on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with/without post-operative physiotherapy is lacking. AIM/OBJECTIVES: To systematically summarise the literature on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with or without post-operative physiotherapy in patients with cervical radiculopathy. METHODS: PubMed, Embase, CINAHL, PsycINFO and Web of Science were searched from inception to 1st of March 2023. Primary outcomes were effectiveness regarding costs, arm pain intensity and disability. Neck pain intensity, perceived recovery, quality of life, neurological symptoms, range-of-motion, return-to-work, medication use, (re)surgeries and adverse events were considered secondary outcomes. Randomised clinical trials comparing personalised multimodal physiotherapy versus surgical approaches with/without post-operative physiotherapy were included. Two independent reviewers performed study selection, data-extraction, and risk of bias assessment using the Cochrane RoB 2 and Consolidated Health Economic Evaluation Reporting Standards statement. Certainty of the evidence was determined using Grading of Recommendations, Assessment, Development and Evaluations. RESULTS: From 2109 records, eight papers from two original trials, with 117 participants in total were included. Low certainty evidence showed there were no significant differences on arm pain intensity and disability, except for the subscale 'heavy work' related disability (12 months) and disability at 5-8 years. Cost-effectiveness was not assessed. There was low certainty evidence that physiotherapy improved significantly less on neck pain intensity, sensory loss and perceived recovery compared to surgery with/without physiotherapy. Low certainty evidence showed there were no significant differences on numbness, range of motion, medication use, and quality of life. No adverse events were reported. CONCLUSION: Considering the clinical importance of accurate management recommendations and the current low level of certainty, high-quality cost-effectiveness studies are needed.

Differences in the organization of the primary motor cortex in people with and without low back pain and associations with motor control and sensory tests.

Differences in organization of the primary motor cortex and altered trunk motor control (sensing, processing and motor output) have been reported in people with low back pain (LBP). Little is known to what extent these differences are related. We investigated differences in 1) organization of the primary motor cortex and 2) motor and sensory tests between people with and without LBP, and 3) investigated associations between the organization of the primary motor cortex and motor and sensory tests. We conducted a case-control study in people with (N=25) and without (N=25) LBP. The organization of the primary motor cortex (Center of Gravity (CoG) and Area of the cortical representation of trunk muscles) was assessed using neuronavigated transcranial magnetic stimulation, based on individual MRIs. Sensory tests (quantitative sensory testing, graphaesthesia, two-point discrimination threshold) and a motor test (spiral-tracking test) were assessed. Participants with LBP had a more lateral and lower location of the CoG and a higher temporal summation of pain. For all participants combined, better vibration test scores were associated with a more anterior, lateral, and lower CoG and a better two-point discrimination threshold was associated with a lower CoG. A small subset of variables showed significance. Although this aligns with the concept of altered organization of the primary motor cortex in LBP, there is no strong evidence of the association between altered organization of the primary motor cortex and motor and sensory test performance in LBP. Focusing on subgroup analyses regarding pain duration can be a topic for future research.

Pain exacerbation following physical activity in adults with diabetic neuropathy: Ecological momentary assessment of foot symptoms.

BACKGROUND AND OBJECTIVES: People with diabetic peripheral neuropathy (DPN) report fluctuating foot symptoms. This study used ecological momentary assessment to: (1) compare foot symptoms between days, time points and periods with/without preceding physical activity or pain medication; and (2) determine relationships between symptoms and endogenous pain modulation. METHOD: Ten low-active Australian adults with probable DPN underwent temporal summation of pain (TSP) and conditioned pain modulation (CPM) then completed mobile phone surveys five times daily for seven days, where they recorded the intensity of six foot symptoms and whether they performed physical activity or consumed pain medication in the preceding three hours.  RESULTS: All foot symptoms except numbness were greater in periods following physical activity, whereas periods following pain medication showed greater shooting pain. TSP showed very large correlations with sensitivity to touch, burning pain, shooting pain and prickling/tingling.  DISCUSSION: General practitioners should be aware that physical activity might exacerbate symptoms of DPN when encouraging their patients to be active.

Mild untreated hypercholesterolaemia affects mechanical properties of the Achilles tendon but not gastrocnemius muscle.

Tendon xanthoma and altered mechanical properties have been demonstrated in people with familial hypercholesterolaemia. However, it is unclear whether mild, untreated hypercholesterolaemia alters musculotendinous mechanical properties and muscle architecture. We conducted a case-control study of adults aged 50 years and over, without lower limb injury or history of statin medication. Based on fasting low-density lipoprotein (LDL) cholesterol levels, 6 participants had borderline high LDL (>3.33 mmol/L) and 6 had optimal LDL cholesterol (<2.56 mmol/L). Using shear wave elastography, shear wave velocity (SWV) of the Achilles tendon and gastrocnemius medialis muscle (a proxy for stiffness), along with muscle fascicle length and pennation angle were measured under four passive tensile loads (0, 0.5, 1.0, 1.5 kg) applied via a pulley system. Differences between groups were found for tendon SWV but not muscle SWV, fascicle length or pennation angle. Participants with hypercholesterolaemia showed greater SWV (mean difference, 95 % CI: 2.4 m/s, 0.9 to 4.0, P = 0.024) compared to the control group across all loads. These findings suggest that adults with mild hypercholesterolaemia have increased tendon stiffness under low passive loads, while muscle was not affected. Future research is needed to confirm findings in a larger cohort and explore the impact of hypercholesterolaemia on tendon fatigue injury and tendinopathy.

Does having an external focus in immersive virtual reality increase range of motion in people with neck pain?

BACKGROUND: When instructing exercises to improve Range of Motion (ROM), clinicians often create an internal focus of attention, while motor performance may improve more when using an external focus. OBJECTIVES: Using Virtual Reality (VR), we investigated the effect of tasks with an internal and external focus on maximal ROM in people with neck pain and explored whether this effect was associated with fear of movement. METHOD: In this cross-over experimental design study, the cervical ROM of 54 participants was measured while performing a target-seeking exercise in a VR-environment (external focus task) and during three maximal rotation and flexion-extension movements with the VR-headset on, without signal (internal focus task). The main statistical analysis included two dependent T-tests. Pearson correlation coefficients were calculated to investigate whether the differences in ROM in both conditions were correlated to fear of movement. RESULTS: Maximal neck rotation was larger in the external focus condition than in the internal focus condition (mean difference: 26.4°, 95% CI [20.6, 32.3]; p < 0.001, d = 1.24). However, there was a difference favouring the internal focus condition for flexion-extension (mean difference: 8.2°, 95% CI [-14.9, -1.5]; p = 0.018, d = 0.33). The variability in ROM was not explained by variability in fear of movement (for all correlations p ≥ 0.197). CONCLUSION: An external focus resulted in a larger range of rotation, but our flexion-extension findings suggest that the task has to be specific to elicit such an effect. Further research, using a task that sufficiently elicits movement in all directions, is needed to determine the value of an external focus during exercise.

Illness perceptions in people with chronic and disabling non-specific neck pain seeking primary healthcare: a qualitative study.

BACKGROUND: Illness perceptions can affect the way people with musculoskeletal pain emotionally and behaviorally cope with their health condition. Understanding patients illness perceptions may help facilitate patient-centered care. The purpose of this study was to explore illness perceptions and the origin of those perceptions in people with chronic disabling non-specific neck pain seeking primary care. METHODS: A qualitative study using a deductive and inductive analytical approach was conducted in 20 people with persistent (> 3 months) and disabling (i.e., Neck Disability Index ≥ 15) neck pain. Using a semi-structured format, participants were interviewed about their illness perceptions according to Leventhal's Common Sense Model. Purposive sampling and member checking were used to secure validity of study results. RESULTS: Participants reported multiple symptoms, thoughts and emotions related to their neck pain, which continuously required attention and action. They felt trapped within a complex multifactorial problem. Although some participants had a broader biopsychosocial perspective to understand their symptoms, a biomedical perspective was dominant in the labelling of their condition and their way of coping (e.g., limiting load, building strength and resilience, regaining mobility, keep moving and being meaningful). Their perceptions were strongly influenced by information from clinicians. Several participants indicated that they felt uncertain, because the information they received was contradictory or did not match their own experiences. CONCLUSION: Most participants reported that understanding their pain was important to them and influenced how they coped with pain. Addressing this 'sense making process' is a prerequisite for providing patient-centered care.

Associations between facial expressions and observational pain in residents with dementia and chronic pain.

AIM: To identify specific facial expressions associated with pain behaviors using the PainChek application in residents with dementia. DESIGN: This is a secondary analysis from a study exploring the feasibility of PainChek to evaluate the effectiveness of a social robot (PARO) intervention on pain for residents with dementia from June to November 2021. METHODS: Participants experienced PARO individually five days per week for 15 min (once or twice) per day for three consecutive weeks. The PainChek app assessed each resident's pain levels before and after each session. The association between nine facial expressions and the adjusted PainChek scores was analyzed using a linear mixed model. RESULTS: A total of 1820 assessments were completed with 46 residents. Six facial expressions were significantly associated with a higher adjusted PainChek score. Horizontal mouth stretch showed the strongest association with the score, followed by brow lowering parting lips, wrinkling of the nose, raising of the upper lip and closing eyes. However, the presence of cheek raising, tightening of eyelids and pulling at the corner lip were not significantly associated with the score. Limitations of using the PainChek app were identified. CONCLUSION: Six specific facial expressions were associated with observational pain scores in residents with dementia. Results indicate that automated real-time facial analysis is a promising approach to assessing pain in people with dementia. However, it requires further validation by human observers before it can be used for decision-making in clinical practice. IMPACT: Pain is common in people with dementia, while assessing pain is challenging in this group. This study generated new evidence of facial expressions of pain in residents with dementia. Results will inform the development of valid artificial intelligence-based algorithms that will support healthcare professionals in identifying pain in people with dementia in clinical situations. REPORTING METHOD: The study adheres to the CONSORT reporting guidelines. PATIENT OR PUBLIC CONTRIBUTION: One resident with dementia and two family members of people with dementia were consulted and involved in the study design, where they provided advice on the protocol, information sheets and consent forms, and offered valuable insights to ensure research quality and relevance. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry number (ACTRN12621000837820).

Investigating the associations between lumbar paraspinal muscle health and age, BMI, sex, physical activity, and back pain using an automated computer-vision model: a UK Biobank study.

BACKGROUND CONTEXT: The role of lumbar paraspinal muscle health in back pain (BP) is not straightforward. Challenges in this field have included the lack of tools and large, heterogenous datasets to interrogate the association between muscle health and BP. Computer-vision models have been transformative in this space, enabling the automated quantification of muscle health and the processing of large datasets. PURPOSE: To investigate the associations between lumbar paraspinal muscle health and age, sex, BMI, physical activity, and BP in a large, heterogenous dataset using an automated computer-vision model. DESIGN: Cross-sectional study. PATIENT SAMPLE: Participants from the UK Biobank with abdominal Dixon fat-water MRI (N=9,564) were included (41.8% women, mean [SD] age: 63.5 [7.6] years, BMI: 26.4 [4.1] kg/m2) of whom 6,953 reported no pain, 930 acute BP, and 1,681 chronic BP. OUTCOME MEASURES: Intramuscular fat (IMF) and average cross-sectional area (aCSA) were automatically derived using a computer-vision model for the left and right lumbar multifidus (LM), erector spinae (ES), and psoas major (PM) from the L1 to L5 vertebral levels. METHODS: Two-tailed partial Pearson correlations were generated for each muscle to assess the relationships between the muscle measures (IMF and aCSA) and age (controlling for BMI, sex, and physical activity), BMI (controlling for age, sex, and physical activity), and physical activity (controlling for age, sex, and BMI). One-way ANCOVA was used to identify sex differences in IMF and aCSA for each muscle while controlling for age, BMI, and physical activity. Similarly, one-way ANCOVA was used to identify between-group differences (no pain, acute BP, and chronic BP) for each muscle and along the superior-inferior expanse of the lumbar spine while controlling for age, BMI, sex, and physical activity (α=0.05). RESULTS: Females had higher IMF (LM mean difference [MD]=11.1%, ES MD=10.2%, PM MD=0.3%, p<.001) and lower aCSA (LM MD=47.6 mm2, ES MD=350.0 mm2, PM MD=321.5 mm2, p<.001) for all muscles. Higher age was associated with higher IMF and lower aCSA for all muscles (r≥0.232, p<.001) except for LM and aCSA (r≤0.013, p≥.267). Higher BMI was associated with higher IMF and aCSA for all muscles (r≥0.174, p<.001). Higher physical activity was associated with lower IMF and higher aCSA for all muscles (r≥0.036, p≤.002) except for LM and aCSA (r≤0.010, p≥.405). People with chronic BP had higher IMF and lower aCSA than people with no pain (IMF MD≤1.6%, aCSA MD≤27.4 mm2, p<.001) and higher IMF compared to acute BP (IMF MD≤1.1%, p≤.044). The differences between people with BP and people with no pain were not spatially localized to the inferior lumbar levels but broadly distributed across the lumbar spine. CONCLUSIONS: Paraspinal muscle health is associated with age, BMI, sex, and physical activity with the exception of the association between LM aCSA and age and physical activity. People with BP (chronic>acute) have higher IMF and lower aCSA than people reporting no pain. The differences were not localized but broadly distributed across the lumbar spine. When interpreting measures of paraspinal muscle health in the research or clinical setting, the associations with age, BMI, sex, and physical activity should be considered.

Systemic Inflammation, Sleep, and Psychological Factors Determine Recovery Trajectories for People With Neck Pain: An Exploratory Study.

We conducted an explorative prospective cohort study with 6 months follow-up to 1) identify different pain and disability trajectories following an episode of acute neck pain, and 2) assess whether neuroimmune/endocrine, psychological, behavioral, nociceptive processing, clinical outcome, demographic and management-related factors differ between these trajectories. Fifty people with acute neck pain (ie, within 2 weeks of onset) were included. At baseline, and at 2, 4, 6, 12, and 26 weeks follow-up, various neuroimmune/endocrine (eg, inflammatory cytokines and endocrine factors), psychological (eg, stress symptoms), behavioral (eg, sleep disturbances), nociceptive processing (eg, condition pain modulation), clinical outcome (eg, trauma), demographic factors (eg, age), and management-related factors (eg, treatment received) were assessed. Latent class models were performed to identify outcome trajectories for neck pain and disability. Linear mixed models or the Pearson chi-square test were used to evaluate differences in these factors between the trajectories at baseline and at each follow-up assessment and over the entire 6 months period. For pain, 3 trajectories were identified. The majority of patients were assigned to the "Moderate pain - Favourable recovery" trajectory (n = 25; 50%) with smaller proportions assigned to the "Severe pain - Favourable recovery" (n = 16; 32%) and the "Severe pain - Unfavourable recovery" (n = 9; 18%) trajectories. For disability, 2 trajectories were identified: "Mild disability - Favourable recovery" (n = 43; 82%) and "Severe disability - Unfavourable recovery" (n = 7; 18%). Ongoing systemic inflammation (increased high-sensitive C-reactive protein), sleep disturbances, and elevated psychological factors (such as depression, stress and anxiety symptoms) were mainly present in the unfavorable outcome trajectories compared to the favorable outcome trajectories. PERSPECTIVE: Using exploratory analyses, different recovery trajectories for acute neck pain were identified based on disability and pain intensity. These trajectories were influenced by systemic inflammation, sleep disturbances, and psychological factors.

Exploring health and illness perceptions to identify the perceived cause of pregnancy-related pelvic girdle pain. A mixed-methods study among primiparous women in The Netherlands.

BACKGROUND: Pregnancy-related pelvic girdle pain (PPGP) is common and considered a multifactorial condition with biomechanical and psychosocial contributions. The patient's perceived cause is an important aspect of illness perceptions, and a strong predictor of self-management and healthcare utilization. It is unknown what causal beliefs primiparae hold regarding PPGP. OBJECTIVE: To explore and describe health and illness perceptions among primiparae towards PPGP and its cause. DESIGN: Exploratory, convergent parallel mixed-methods. SETTING: At the participants' homes. PARTICIPANTS: Sixteen primiparae with and without PPGP. FINDINGS: Primiparae with and without PPGP held comparable causal beliefs about PPGP. PPGP was described as the result of hormonal softening and loosening of the pelvis, and failure of the muscular system to compensate for that. Women who experienced similar physical symptoms attributed them differently, leading to different coping strategies. Interestingly, maternal healthcare providers reinforced the unidimensional- and predominantly biomechanical view when women sought healthcare. CONCLUSION: The causal mechanism of PPGP held by the women was not determined by their lived experience. It was primarily based on the concept of inevitable hormonal softening of the pelvis. This biomechanical belief is based on theories that are not in line with current knowledge of PPGP and contemporary pain science, yet they were reinforced by maternity healthcare providers. IMPLICATIONS FOR PRACTICE: Healthcare seeking behavior is influenced by illness beliefs. Maternity healthcare providers may play a key role in providing reassurance and addressing the multifactorial nature of PPGP when providing care and support to pregnant women.

The impact of being overweight or obese on 12 month clinical recovery in patients following lumbar microdiscectomy for radiculopathy.

BACKGROUND CONTEXT: The proportion of patients who undergo lumbar microdiscectomy due to lumbar radiculopathy who are also overweight or obese is high. However, whether high body mass index (BMI) affects clinical outcomes is not well-studied. PURPOSE: To investigate the difference in the clinical course between normal weight, overweight, and obese patients with radiculopathy who underwent lumbar microdiscectomy followed by physical therapy and to evaluate whether high BMI is associated with poor recovery. STUDY DESIGN/SETTING: A prospective cohort study with a 12-month follow-up was conducted in a multidisciplinary clinic. PATIENT SAMPLE: We included 583 patients (median [IQR] age: 45 [35-52] years; 41% female) with clinical signs and symptoms of lumbar radiculopathy, consistent with magnetic resonance imaging findings, who underwent microdiscectomy followed by postoperative physical therapy. OUTCOME MEASURES: Outcomes were leg pain and back pain intensity measured with a visual analogue scale, disability measured with the Roland Morris Disability Questionnaire at 3 and 12-month follow-ups, and complications. METHODS: Patients were classified as being normal weight (46.9%), overweight (38.4%), or obese (14.7%). A linear mixed-effects model was used to assess the difference in the clinical course of pain and disability between the three BMI categories. The association between BMI and outcomes was evaluated using univariable and multivariable logistic regression analyses. RESULTS: All three patient groups experienced a significant improvement in leg pain, back pain, and disability over 3 and 12-month follow-up. Patients who were overweight, obese, or normal weight experienced comparable leg pain (p=.14) and disability (p=.06) over the clinical course (p=.14); however, obese patients experienced higher back pain (MD=-6.81 [95%CI: -13.50 to -0.14]; p=.03). The difference in back pain scores was not clinically relevant. CONCLUSIONS: In the first year following lumbar microdiscectomy, patients demonstrated clinical improvements and complications that were unrelated to their preoperative BMI.

Efficacy of Conservative Interventions for Musculoskeletal Conditions on Pain and Disability in Active Serving Military Personnel-A Systematic Review.

INTRODUCTION: Musculoskeletal (MSK) injuries and associated pain disorders are one of the leading causes for soldiers not being medically fit for deployment, impacting force capability and readiness. Musculoskeletal pain continues to be a leading cause of disability within military services and is associated with a substantial financial burden. A better understanding of the effectiveness of MSK pain management strategies is required. This review was designed to determine the efficacy of nonsurgical interventions, such as physiotherapy, exercise, pharmacology, and multidisciplinary programs, to manage MSK conditions in active serving military populations. MATERIALS AND METHODS: MEDLINE, Embase, CINAHL, and SPORTDiscus were searched to identify relevant randomized clinical trials. Recommended methods were used for article identification, selection, and data extraction. The Cochrane Risk of Bias tool and the Grade of Recommendation, Assessment, Development, and Evaluation were used to appraise the studies. Where possible, meta-analyses were performed. The review was conducted according to the PRISMA guidelines. RESULTS: Nineteen articles (1,408 participants) met the eligibility criteria. Low back pain (LBP) was the most frequently investigated condition, followed by knee pain, neck pain, and shoulder pain. Early physiotherapy, exercise and adjunct chiropractic manipulation (for LBP), and multidisciplinary pain programs (physiotherapy, occupational therapy, and psychology) (for chronic MSK pain) improved pain (standardized mean difference ranged from -0.39 to -1.34; low strength of evidence). Participation in multidisciplinary pain programs, adjunct chiropractic manipulation, and early physiotherapy improved disability (for LBP) (standardized mean difference ranged from -0.45 to -0.86; low to very low strength of evidence). No studies evaluated pain medication. Dietary supplements (glucosamine, chondroitin sulfate, and manganese ascorbate), electrotherapy, isolated lumbar muscle exercises, home cervical traction, or training in virtual reality showed no benefit. The studies had a high risk of bias, were typically underpowered, and demonstrated high clinical heterogeneity. CONCLUSIONS: Currently available randomized clinical trials do not provide sufficient evidence to guide military organizations or health care professionals in making appropriate treatment decisions to manage MSK pain in active serving military personnel. Future research is essential to enable evidence-based recommendations for the effective management of MSK pain conditions in this unique population.

Personal Activity Intelligence eHealth intervention in people with diabetic peripheral neuropathy: A feasibility study.

BACKGROUND AND OBJECTIVES: People with diabetic peripheral neuropathy (DPN) report difficulty exercising. This study tested an innovative intervention to promote physical activity self-management and its impact on foot symptoms. METHOD: Ten adults with DPN not meeting exercise guidelines consented to four weekly sessions involving exercise tasters, behaviour change counselling and Physical Activity Intelligence (PAI) self-monitoring, with a goal to maintain daily PAI scores ≥100. Foot symptoms were assessed using repeated mobile phone surveys at 0 and 12 weeks. RESULTS: Participants attended a mean 3.5 sessions and achieved 100 PAI on 53% and 15% of days during Weeks 2-4 and 5-12, respectively. No major adverse events and large reductions in aching (P=0.02) and burning pain (P=0.03) in the feet were recorded. DISCUSSION: The PAI eHealth intervention was feasible and safe and might reduce foot symptoms. More work is needed to support self-directed exercise maintenance.