The lived experience of chronic pain for Maori: how can this inform service delivery and clinical practice? A systematic review and qualitative synthesis.

AIM: To synthesise the literature describing experiences of chronic pain and pain management for Maori, and to understand how this experience could inform service delivery and clinical practice. METHOD: We systematically searched for qualitative research on Maori chronic pain experiences (Scopus, Medline, APA PsycINFO, NZ Research, Research Square). Data extracted were coded and synthesised using thematic analysis. RESULTS: Seven studies were included. Three themes encapsulated the data: 1) a multidimensional view of pain and pain management: Maori expressed a holistic and integrated understanding of the multiple factors that influence pain and its management, 2) a responsibility: respectful tikanga-informed care: the experiences of Maori participants with healthcare highlight a need for antiracist approaches, and a clinical responsibility to practice manaakitanga and tikanga, and 3) tino rangatiratanga: a desire for knowledge, choice and autonomy in pain management: Maori valued the empowering nature of knowledge about pain, and information and support to make decisions about treatment, including considerations regarding Western and traditional Maori medicine. CONCLUSION: Health services need to understand and respect the multidimensional aspects of pain, minimise racism and discrimination, use whakawhanaungatanga, manaakitanga, and tikanga-informed practices, and provide appropriate information to support tino rangatiratanga for pain management.

The autonomic and nociceptive response to acute experimental stress is impaired in people with knee osteoarthritis: A preliminary study.

Objective: Alterations in autonomic function are evident in some chronic pain conditions but have not been thoroughly examined in people with osteoarthritis (OA). The study aimed to examine resting autonomic nervous system (ANS) function in people with knee OA, and the response of the autonomic and nociceptive systems to acute stress. Methods: A preliminary cross-sectional study was undertaken involving people with knee OA (n = 14), fibromyalgia (n = 13), and pain-free controls (n = 15). The sympathetic and parasympathetic components of the ANS were assessed through measures of pre-ejection period (PEP), skin conductance level (SCL), and high frequency heart rate variability (HF HRV). The nociceptive system was assessed through pain ratings associated with a tonic heat pain stimulus. In separate sessions, ANS and heat pain measures were assessed at rest and in response to nociceptive and mental arithmetic stressors. Results: The knee OA group showed reduced HF HRV at rest and reduced modulation in response to stress. Resting PEP and SCL were normal in the knee OA group but PEP modulation was impaired in both chronic pain groups during nociceptive stress. The expected reduction in tonic heat pain ratings in response to stress was lacking in the knee OA and FM groups. Conclusion: Preliminary evidence shows impaired parasympathetic nervous system function at rest and in response to nociceptive and mental stress in people with knee OA, with some evidence of altered sympathetic nervous system function. Impaired ANS function could contribute to ongoing pain experienced, and interventions that target ANS function could be beneficial.

Health and illness beliefs regarding pain and pain management of New Zealand resident Samoan community leaders: A qualitative interpretive study based on Pasifika paradigms.

ISSUE ADDRESSED: Ethnic disparities in chronic pain exist in Aotearoa New Zealand, including a greater impact of pain, less access to chronic pain services and less benefit from treatment for Pasifika people. This study investigated Samoan health perceptions and beliefs in relation to pain and how it is managed. METHODS: An interpretive descriptive study was undertaken involving interviews with nine Samoan key informants from Aotearoa New Zealand. Interviews explored their beliefs in relation to interpretations of pain and experiences of and preferences for pain management. Interviews were recorded and transcribed. Data were analysed using thematic analysis. RESULTS: Four main themes were constructed from the data. Pain is interpreted holistically described the attribution of pain to many causes, without limitation to physiological explanations. Stoicism is a character virtue described the predominant belief that pain should be endured without display or complaint. Strength in connectivity described the inherent pain coping strategies that are present within Samoan communities. To improve healthcare is to nurture va described the disconnect Samoan people feel from healthcare services and the need to foster relationships to improve health delivery. CONCLUSIONS: Samoan people have beliefs and perceptions about pain and its management that extend beyond traditional Western interpretations. While pain is often endured using traditional strengths within the 'aiga (family) and community, the Samoan community faces challenges in receiving healthcare from mainstream pain services. SO WHAT?: Clinicians need to foster stronger relationships with Samoan individuals and their 'aiga and appreciate the wider psychosocial context of pain, including spirituality.

Preoperative predictors for return to physical activity following anterior cruciate ligament reconstruction (ACLR): a systematic review.

BACKGROUND: Rates of return to physical activity after anterior cruciate ligament reconstruction surgery are sub-optimal. Optimising presurgical treatment may improve return rates. The purpose of this systematic review was to identify modifiable preoperative predictors for return to physical activity after anterior cruciate ligament reconstruction. METHODS: Seven electronic databases (CINAHL, MEDLINE and SPORTDiscus via EBSCOhost, AMED, PsycINFO and EMBASE via OVID and Web of Science) were searched from inception to 31 March 2023. The population of focus was adults aged 18-65 who had undergone primary anterior cruciate ligament reconstruction. Studies needed to identify at least one potential modifiable preoperative predictor variable and the relationship between the predictor(s) and return to physical activity. All time-points of assessment and study designs were included. Data extraction was completed by one reviewer and verified by a second reviewer. Two reviewers completed the risk of bias assessment using the Quality in Prognostic Studies tool and Grading of Recommendations Assessment, Development and Evaluation system. RESULTS: The search identified 2281 studies, eight met the inclusion criteria. Five studies scored 'high', and three studies scored 'moderate' risk-of-bias. All preoperative predictors were of very low-quality evidence. Five different outcome measures were used to assess return to physical activity including Tegner, Marx, Physical Activity Scale, return to play at the elite level and return to preinjury level (undefined). This was measured between 1- and 10-years post-surgery. Nine preoperative physical, six psychosocial and five demographic/clinical factors were assessed and four were found to be predictive. These included quadriceps strength, psychological profile, patient estimated ability to return and graft type (patella tendon, BPTB). CONCLUSION: Very-low level evidence suggests that increasing quadriceps strength, managing patient expectations of their treatment outcomes, improving motivation to resume preinjury activity levels and considering the use of a BPTB graft will support return to physical activity after ACLR. TRIAL REGISTRATION: This study was prospectively registered in PROSPERO: CRD 42020222567.

NZ-RugbyHealth Study: Current Postural Control Ability of Former Rugby Union and Non-contact Sport Players.

BACKGROUND: Players in contact sports frequently experience mild traumatic brain (concussion) injuries (TBI). While there are known disruptions to balance following acute head trauma, it is uncertain if sport-related concussion injuries have a lasting impact on postural control. AIM: To assess postural control in retired rugby players in comparison to retired non-contact sport players, and to evaluate any association with self-reported sport-related concussion history. METHODS: Using a cross-sectional design, 75 players in the NZ-RugbyHealth study from three sports groups (44 ± 8 years; 24 elite rugby, 30 community rugby, 21 non-contact sport) took part in this study. The SMART EquiTest® Balance Master was used to assess participant's ability to make effective use of visual, vestibular and proprioceptive information using standardised tests. Postural sway was also quantified using centre of pressure (COP) path length. The relationship among sports group, sport-related concussion history and postural control was evaluated using mixed regression models while controlling for age and body mass index. RESULTS: Limited significant differences in balance metrics were found between the sports groups. A statistically significant (p < 0.001) interaction indicated a relationship between COP path length and sport-related concussion history in the most challenging balance condition, such that path length increased as the number of previous sport-related concussions increased. CONCLUSION: There was some evidence for a relationship between sport-related concussion recurrence in sports players and postural stability in challenging balance conditions. There was no evidence of impaired balance ability in retired rugby players compared with non-contact sport athletes.

Chinese and Indian interpretations of pain: A qualitative evidence synthesis to facilitate chronic pain management.

OBJECTIVE: People from minority ethnicities often have a greater impact of chronic pain, are underrepresented at pain services, and may not benefit from treatment to the same extent as dominant cultures. The aim of this study was to review Indian and Chinese cultural views of pain and pain management, as a basis for improving management of chronic pain in migrant populations from these ethnicities. METHODS: A systematic review of qualitative studies addressing pain beliefs and experiences involving Indian and Chinese participants was conducted. Thematic synthesis was used to identify themes across the studies, and the quality of the articles was appraised. RESULTS: Twenty-six articles were included, most of which were appraised as high quality. Five themes were identified: Making meaning of pain described the holistic interpretation of the meaning of pain; Pain is disabling and distressing described the marked physical, psychological, and spiritual impact of pain; Pain should be endured described the cultural expectation to suppress responses to pain and not be a burden; Pain brings strength and spiritual growth described the enrichment and empowerment some people experienced through living with pain, and Management of pain goes beyond a traditional or Western approach described the factors that guided people in their use of healthcare. DISCUSSION: The review identified a holistic interpretation and impact of pain in Indian and Chinese populations, with pain management guided by multiple factors that transcended a single cultural framework. Several strength-based management strategies are recommended based on preferences for traditional treatments and respect for Western healthcare.

Trajectories of Pain and Function Outcomes up to 5 to 8 Years Following Total Knee Arthroplasty.

BACKGROUND: There appears to be substantial variability in outcomes > 2 years following total knee arthroplasty (TKA) that is masked by whole group analyses. The goal of the study was to identify trajectories of pain and function outcomes up to 5 to 8 years post-TKA and to identify baseline factors that are associated with different trajectories of recovery. METHODS: Baseline, 6-month, and 12-month pain and function data were collected in a previous study investigating predictors of outcome following primary TKA (n = 286), along with a variety of baseline predictor variables. The present study obtained pain and function data at 5 to 8 years following TKA in the same cohort (n = 201). Latent class linear mixed models were used to identify different classes of pain and functional trajectories over time. The extent to which differences across latent classes were explained by baseline predictor variables was determined. RESULTS: Three classes of pain and two classes of function trajectory were identified. While most patients (84% to 93%) followed a trajectory that showed an initial rapid gain following surgery that was sustained through 5 to 8 years, both pain and function included at least one trajectory class that showed a meaningful change after 12 months. No predictor variables were significantly associated with either the pain or function classes. CONCLUSIONS: Most patients follow a traditional trajectory of recovery in knee pain and function over 5 to 8 years. However, alternative trajectories are observed in an important minority of patients such that knee pain and function at 12 months after surgery does not always reflect outcomes at 5 to 8 years.

The autonomic and nociceptive response to acute exercise is impaired in people with knee osteoarthritis.

Objectives: An acute bout of exercise typically leads to short term exercise induced hypoalgesia (EIH), but this response is more variable in many chronic pain populations, including knee osteoarthritis (OA) and fibromyalgia (FM). There is evidence of autonomic nervous system (ANS) dysfunction in some chronic pain populations that may contribute to impaired EIH, but this has not been investigated in people with knee OA. The aim of this study was to assess the acute effects of isometric exercise on the nociceptive and autonomic nervous systems in people with knee OA and FM, compared to pain-free controls. Methods: A cross-sectional study was undertaken with 14 people with knee OA, 13 people with FM, and 15 pain free controls. Across two experimental sessions, baseline recordings and the response of the nociceptive and autonomic nervous systems to a 5-min submaximal isometric contraction of the quadriceps muscle was assessed. The nociceptive system was assessed using pressure pain thresholds at the knee and forearm. The ANS was assessed using high frequency heart rate variability, cardiac pre-ejection period, and electrodermal activity. Outcome measures were obtained before and during (ANS) or immediately after (nociceptive) the acute bout of exercise. Results: Submaximal isometric exercise led to EIH in the control group. EIH was absent in both chronic pain groups. Both chronic pain groups showed lower vagal activity at rest. Furthermore, people with knee OA demonstrated reduced vagal withdrawal in response to acute isometric exercise compared to controls. Sympathetic reactivity was similar across groups. Discussion: The findings of reduced tonic vagal activity and reduced autonomic modulation in response to isometric exercise raise the potential of a blunted ability to adapt to acute exercise stress and modulate nociception in people with knee OA. The impairment of EIH in knee OA may, in part, be due to ANS dysfunction.

What factors predict outcome from an inpatient multidisciplinary chronic pain service? A prospective cohort study.

Objective To identify baseline factors associated with outcomes from an inpatient multidisciplinary pain management program (PMP) located in a bicultural area of Aotearoa New Zealand. Methods A prospective cohort study was undertaken involving 164 people with chronic pain who attended the PMP. Demographic, clinical, and psychosocial measures were obtained at baseline, whereas clinical and psychosocial outcome measures were also obtained at program discharge and 3-month follow up (N = 100). Multivariate analyses were used to determine baseline demographic variables that were associated with outcomes at discharge and follow up. Results Being male and working full-time were associated with poorer outcomes in select measures at discharge. At the 3-month follow up, Maori ethnicity, working full-time, being retired or unemployed, or having chronic widespread pain were associated with poorer outcomes for some measures, whereas those with rheumatoid arthritis had greater self-efficacy. Conclusions Sex, ethnicity, employment status, and patient condition impact clinical outcomes from the program and in the time from discharge to follow up. Program content and/or delivery should be altered to promote more equitable outcomes for all patients in the long term.

A combination of high preoperative pain and low radiological grade of arthritis is associated with a greater intensity of persistent pain 12 months after total knee arthroplasty.

AIMS: Despite new technologies for total knee arthroplasty (TKA), approximately 20% of patients are dissatisfied. A major reason for dissatisfaction and revision surgery after TKA is persistent pain. The radiological grade of osteoarthritis (OA) preoperatively has been investigated as a predictor of the outcome after TKA, with conflicting results. The aim of this study was to determine if there is a difference in the intensity of pain 12 months after TKA in relation to the preoperative radiological grade of OA alone, and the combination of the intensity of preoperative pain and radiological grade of OA. METHODS: The preoperative data of 300 patients who underwent primary TKA were collected, including clinical information (age, sex, preoperative pain), psychological variables (depression, anxiety, pain catastrophizing, anticipated pain), and quantitative sensory testing (temporal summation, pressure pain thresholds, conditioned pain modulation). The preoperative radiological severity of OA was graded according to the Kellgren-Lawrence (KL) classification. Persistent pain in the knee was recorded 12 months postoperatively. Generalized linear models explored differences in postoperative pain according to the KL grade, and combined preoperative pain and KL grade. Relative risk models explored which preoperative variables were associated with the high preoperative pain/low KL grade group. RESULTS: Pain 12 months after TKA was not associated with the preoperative KL grade alone. Significantly increased pain 12 months after TKA was found in patients with a combination of high preoperative pain and a low KL grade (p = 0.012). Patients in this group were significantly more likely to be male, younger, and have higher preoperative pain catastrophizing, higher depression, and lower anxiety (all p ≤ 0.05). CONCLUSION: Combined high preoperative pain and low radiological grade of OA, but not the radiological grade alone, was associated with a higher intensity of pain 12 months after primary TKA. This group may have a more complex cause of pain that requires additional psychological interventions in order to optimize the outcome of TKA.Cite this article: Bone Joint J 2022;104-B(11):1202-1208.

Active Virtual Reality for Chronic Primary Pain: Mixed Methods Randomized Pilot Study.

BACKGROUND: The modern management of chronic pain is largely focused on improving functional capacity (often despite ongoing pain) by using graded activation and exposure paradigms. However, many people with chronic pain find functional activation programs aversive, and dropout rates are high. Modern technologies such as virtual reality (VR) could provide a more enjoyable and less threatening way for people with chronic pain to engage in physical activity. Although VR has been successfully used for pain relief in acute and chronic pain settings, as well as to facilitate rehabilitation in conditions such as stroke and cerebral palsy, it is not known whether VR can also be used to improve functional outcomes in people with chronic pain. OBJECTIVE: This study aimed to assess the feasibility of conducting an adequately powered randomized controlled trial (RCT) to test the efficacy of VR in a chronic pain treatment center and assess the acceptability of an active VR treatment program for patients in this setting. METHODS: For this mixed methods pilot study, which was designed to test the feasibility and acceptability of the proposed study methods, 29 people seeking treatment for chronic pain were randomized to an active VR intervention or physiotherapy treatment as usual (TAU). The TAU group completed a 6-week waitlist before receiving standard treatment to act as a no-treatment control group. The VR intervention comprised twice-weekly immersive and embodied VR sessions using commercially available gaming software, which was selected to encourage movement. A total of 7 VR participants completed semistructured interviews to assess their perception of the intervention. RESULTS: Of the 99 patients referred to physiotherapy, 53 (54%) were eligible, 29 (29%) enrolled, and 17 (17%) completed the trial, indicating that running an adequately powered RCT in this setting would not be feasible. Despite this, those in the VR group showed greater improvements in activity levels, pain intensity, and pain interference and reported greater treatment satisfaction and perceived improvement than both the waitlist and TAU groups. Relative effect sizes were larger when VR was compared with the waitlist (range small to very large) and smaller when VR was compared with TAU (range none to medium). The qualitative analysis produced the following three themes: VR is an enjoyable alternative to traditional physiotherapy, VR has functional and psychological benefits despite continued pain, and a well-designed VR setup is important. CONCLUSIONS: The active VR intervention in this study was highly acceptable to participants, produced favorable effects when compared with the waitlist, and showed similar outcomes as those of TAU. These findings suggest that a confirmatory RCT is warranted; however, substantial barriers to recruitment indicate that incentivizing participation and using a different treatment setting or running a multicenter trial are needed.

Return-to-work expectations and workplace supports in New Zealand: injured workers' perspectives.

AIM: Work-disability following musculoskeletal injury causes a significant burden for individuals and healthcare systems. Research into work-disability prevention has investigated the ability of psychosocial factors to predict return-to-work in workers with musculoskeletal injuries. Recent research indicates that both return-to-work expectations and workplace supports influence return-to-work outcome. However, how these mechanisms operate to influence outcome is still largely unknown. METHODS: We undertook a qualitative study involving semi-structured interviews with workers from diverse backgrounds who were undergoing vocational rehabilitation in New Zealand following a musculoskeletal injury. Interviews investigated the injured workers' experiences of workplace supports and asked in-depth about what contributed to their expectations of returning to work. Thematic analysis was used to analyse and interpret the data. FINDINGS: Analysis identified four key themes. We found that what workplace supports were offered and how they were taken up was related to systemic factors, and trust. We also identified a link between the offer of support from the workplace and return-to-work expectations. Finally, the actions of workers' compensation and healthcare providers during workers' recovery were reported to influence supports, expectations and the confidence injured workers experienced in their return-to-work outcome in both overt and subtle ways. CONCLUSION: This study indicated that actions of the workplace, healthcare providers and workers' compensation parties can all influence workplace supports, return-to-work expectations and return-to-work outcome. These findings therefore implicate the actions of these stakeholders in work-disability prevention efforts.IMPLICATIONS FOR REHABILITATIONPositive return-to-work expectations are increasingly shown by research to be related to positive return-to-work outcomes for injured workers.Trust between the worker and the company can underpin the provision of supports for return-to-work, which in turn can influence worker confidence and expectations of return-to-work.Consideration of workplace culture and relationships when healthcare providers interact with employers can be crucial in fostering trust and enabling appropriate workplace supports.The ways in which workers compensation processes are executed can also affect workplace relationships, and therefore influence the provision of appropriate return-to-work supports.

NZ-RugbyHealth Study: Self-reported Injury Experience and Current Health of Former Rugby Union and Non-contact Sport Players.

BACKGROUND: There is limited research on associations between playing rugby union and player health post-retirement. OBJECTIVE: This study investigated differences in self-reported sport injury history and current self-reported health characteristics between former New Zealand rugby and non-contact sport players with a view to identifying issues to be further investigated with stronger epidemiological research designs. METHODS: Using a cross-sectional design, the NZ-RugbyHealth study surveyed 470 former rugby and non-contact sport players (43.8 ± 8.1 years; 127 elite rugby, 271 community rugby, 72 non-contact sport) recruited from October 2012 to April 2014. Demographic information, engagement in sport, sport injuries, medical conditions, mood, alcohol and substance use and ratings of current health status were obtained from a self-report 58-item general health e-questionnaire. We highlighted standardised differences in means of > 0.6 and differences in relative percentages of > 1.43 for variables between groups as representing at least moderate effect sizes, and of being worthy of follow-up studies. RESULTS: Higher percentages of the elite rugby player group had sustained injuries of a given body-site type (e.g. neck sprain/strain, thigh bruising, hamstring strain) combination than the non-contact sports players. Higher percentages of the rugby groups reported having sustained concussion (94% for elite, 82% for community, 26% for non-contact), injuries requiring hospitalisation (73%, 46%, 25%), injuries that stopped participation in sport permanently (28%, 28%, 11%) and sport-related surgery (72%, 46%, 32%) during their playing career. Both rugby groups had a higher prevalence of osteoarthritis (37%, 18%, 6%) than non-contact athletes and community rugby players had higher levels of hazardous alcohol consumption (38%, 40%, 25%) in retirement than non-contact athletes. There was little difference between rugby players and non-contact sports athletes in self-reported mood, substance use and current physical or psychological health ratings. CONCLUSIONS: Former rugby player groups were at higher risk than the non-contact player group for most injuries during their playing careers, and in retirement had greater prevalence of osteoarthritis and hazardous alcohol consumption. The relative youth of the groups (43.8 years on average) means that health issues that typically do not emerge until later life may not have yet manifested.

Reduced individual treatment delivery has no effect on outcomes in a multidisciplinary pain management program.

Objective There is little information on how multidisciplinary pain management programs (MPMPs), the gold-standard treatment for people with chronic non-cancer pain, should be structured or delivered. This study compared outcomes from a 3-week in-patient MPMP between those who attended a group-based program that included 8 h of individual therapy each week and those who attended when the amount of individual therapy had been halved. Methods Participants were patients attending an MPMP with a large component of individual sessions (n = 112; Standard) and patients attending the same MPMP after it switched to predominantly group-based sessions (n = 117; Revised). The Hospital Anxiety and Depression Scale (HADS) and Queen Elizabeth (QE) Health Scale were administered to participants at baseline and discharge. Regression analysis was used to compare outcomes between the two delivery formats. Results There were no significant differences in any outcome measures between the two delivery formats overall. The QE Health Scale (P < 0.001) and HADS depression (P < 0.05) scores were significantly better for patients with rheumatoid arthritis or osteoarthritis who had undertaken the Revised program compared with the Standard program. Conclusions This study provides support that changing the amount of individual therapy within in-patient MPMPs does not change patient outcomes. However, there is evidence that those with rheumatoid arthritis and osteoarthritis respond better to a more group-based approach, suggesting that different populations may be suited to different delivery formats. What is known about the topic? Studies have shown mixed results as to whether group- or individual-based rehabilitation programs are more effective. Previous systematic reviews on physiotherapy- or psychological-based interventions have concluded that individual and group approaches are generally equivalent in terms of patient outcomes. MPMPs are trending towards more group-based delivery of content; however, it is unknown whether the equivalence of efficacy between group and individual formats extends to a chronic pain population receiving multidisciplinary care. What does this paper add? This research specifically adds to the knowledge that almost exclusive group delivery of therapy is just as effective as a program with more individual components in a population of patients participating in an MPMP. There is some evidence that those with rheumatoid arthritis and osteoarthritis in the almost exclusive group delivery program had better outcomes than those in the program with more individual components, indicating that specific conditions may benefit more from a group approach. What are the implications for practitioners? Practitioners can be confident that group delivery is just as effective as individual delivery of program components in an MPMP. Thus, decisions regarding the delivery format can be based on factors such as practical considerations, cost or patient and clinician preference.

Mental Health and Wellbeing of Retired Elite and Amateur Rugby Players and Non-contact Athletes and Associations with Sports-Related Concussion: The UK Rugby Health Project.

BACKGROUND: Concerns have intensified over the health and wellbeing of rugby union and league players, and, in particular, about the longer-term effects of concussion. The purpose of this study was to investigate whether there were differences in mental health, sleep and alcohol use between retired elite and amateur rugby code players and non-contact athletes, and to explore associations with sports-related concussion. METHODS: 189 retired elite (ER, n = 83) and amateur (AR, n = 106) rugby code players (rugby union n = 145; rugby league n = 44) and 65 former non-contact athletes (NC) were recruited to the UK Rugby Health Project between 2016 and 2018. Details on sports participation and concussion history were obtained by questionnaire, which also included questions on mental health, anger, sleep, mood, alcohol use, social connections and retirement from injury. Data were compared between sports groups (ER, AR and NC), between exposure of three or more or five or more concussions and for years in sport. RESULTS: ER reported more concussions than AR (5.9 ± 6.3 vs. 3.7 ± 6.3, p = 0.022) and NC (0.4 ± 1.0, p < 0.001). ER had a higher overall negative mental health score (indicating poor mental health) than AR (10.4 ± 6.3 vs. 7.4 ± 6.5, d = 0.47, p = 0.003) and NC (7.1 ± 4.8, d = 0.57, p = 0.006) and a lower overall positive score (indicating good mental health) than NC (8.9 ± 4.1 vs. 10.7 ± 3.4, d = 0.46, p = 0.021). Negative scores were highest and positive scores lowest in those reporting three or more concussions (d = 0.36, p = 0.008; d = 0.28, p = 0.040, respectively) or five or more concussions (d = 0.56, p < 0.001; d = 0.325, p = 0.035, respectively). Reported symptoms for sleep disruption were more prevalent in ER than NC, and in former athletes with three or more concussions (d = 0.41-0.605, p < 0.05). There were no significant differences in alcohol score (p = 0.733). Global anger score and covert anger expression was higher in former athletes with five or more concussions (d = 0.32, p = 0.035; d = 0.37, p = 0.016). AR reported greater attachment to friends than NC (d = 0.46, p = 0.033) and 20% of ER reported that they would not turn to anyone if they had a problem or felt upset about anything. CONCLUSION: There was a significantly higher prevalence of adverse mental health and sleep disruption in ER and in former athletes who reported a higher number of concussions. Anger and irritability were more prevalent in former athletes with a history of five or more concussions. Strategies are needed to address mental health and sleep disturbance in elite rugby code athletes, who are also less likely to seek help should they need it. Further research is needed to elucidate causation, and the neurobiological connection between concussion, sub-concussions and longer-term psychological health and wellbeing.

Preoperative predictors for a successful return to sport following anterior cruciate ligament reconstruction (ACLR): a protocol for a systematic review and meta-analysis.

INTRODUCTION: Return to sport (RTS) following anterior cruciate ligament reconstruction (ACLR) is the primary goal for most patients. However, the decision of when to RTS is difficult for patients and clinicians as it is based on limited available evidence. Over the past decade, a number of predictor variables have been associated with RTS after ACLR. We present a Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols compliant protocol for a systematic review and meta-analysis of preoperative predictors for RTS/preinjury levels of physical activity following ACLR. METHODS AND ANALYSIS: A literature search will be performed in six electronic databases (CINAHL, AMED, MEDLINE, SPORTDiscus and PsycINFO via EBSCOhost and Web of Science) from inception to December 2020. Prospective, retrospective and cross-sectional study designs will be included. To be included, studies will need to identify at least one preoperative predictor and identify the relationship between the predictor(s) and RTS/preinjury levels of physical activity following ACLR. Blinded assessment with consensus agreement will be applied for inclusion of studies, data extraction, risk of bias assessment using the Quality in Prognostic Studies tool and the Grading of Recommendations Assessment, Development and Evaluation framework. If data allows and studies are considered homogeneous, data will be pooled through a meta-analysis. If heterogenous, a narrative synthesis will be completed. Subgroup and sensitivity analyses will be completed, where appropriate. ETHICS AND DISSEMINATION: Ethical permission is not required for this study. The results will be published in a peer-reviewed journal and presented at national and international conferences. PROSPERO REGISTRATION NUMBER: CRD42020222567.

Inequity in outcomes from New Zealand chronic pain services.

AIM: To evaluate outcomes from chronic pain services in New Zealand based on patient ethnicity. METHOD: Clinical and demographic data were obtained from 4,876 patients from the Electronic Persistent Pain Outcomes Collaboration (ePPOC) database, a database of standardised assessments from chronic pain services across New Zealand. Clinical questionnaires included the Brief Pain Inventory (BPI); Depression, Anxiety and Stress Scale - 21 items (DASS-21); Pain Catastrophising Scale (PCS); and the Pain Self-Efficacy Questionnaire (PSEQ). Regression analysis (adjusting for age, body mass index, and baseline values) was used to determine whether patient ethnicity was associated with clinical questionnaire data at treatment end and at 3-6-month follow-up. RESULTS: At treatment end, there were significantly poorer scores for Pacific people compared to Europeans for several of the DASS-21 and PCS subscales, while there were no differences between European and Maori and Asian ethnicities. At follow-up, almost all outcome measures were poorer for Maori compared to European, and several of the DASS-21 and PCS subscales were poorer for Asian and Pacific people compared to Europeans. CONCLUSION: There are ethnic inequalities in the efficacy of treatment for chronic pain services in New Zealand. The cultural safety of the chronic pain clinics should be reviewed regarding both assessment and management procedures.

What Influences Outcomes From Inpatient Multidisciplinary Pain Management Programs?: A Systematic Review and Meta-analysis.

OBJECTIVES: Although inpatient multidisciplinary pain management programs (PMPs) are effective for chronic pain, not all patients benefit equally and there is limited evidence regarding predictors of outcome. This meta-analysis aimed to identify patient or program characteristics associated with outcomes from inpatient PMPs, and to examine the time course of effects following discharge. MATERIALS AND METHODS: Medline, EBSCO, and Scopus were searched to identify articles reporting outcomes from inpatient multidisciplinary PMPs. Information was extracted on study design, participant and program characteristics, and outcomes. Effect sizes were computed for pain, physical function, depression, anxiety, and mental health outcomes. Study-level predictors of outcome were investigated with moderator analyses and meta-regression. A risk of bias assessment and sensitivity analyses were conducted and the GRADE criteria for prognostic studies were applied to assess confidence in findings. RESULTS: In all, 85 studies (111 cohorts; 15,255 participants) were included. Three quarters of studies demonstrated low risk of bias. Larger effect sizes (for at least 1 outcome measure) occurred in studies where participants had more severe pain (greater intensity/longer duration), participants with alcohol or drug problems were not excluded, samples comprised mixed pain conditions, and programs included a cognitive component and/or a passive therapy component. Effect sizes for pain and physical function were maintained at follow-up, but effect sizes for depression and anxiety declined over time. DISCUSSION: Inpatient multidisciplinary PMPs may be well suited to patients with severe or long-lasting pain. Programs should adopt broad patient inclusion criteria, and outcomes were similar for programs based on cognitive-behavioral versus mindfulness/acceptance-based therapies.

Experimental Hand and Knee Pain Cause Differential Effects on Corticomotor Excitability.

Acute pain elicits a well-known inhibitory effect on upper limb corticomotor excitability, whereas the temporal effects of lower-limb experimental pain and pain in a remote limb are less clear. The aim of this study was to compare the temporal corticomotor excitability changes in the upper and lower limbs in response to acute upper and lower limb pain. In a cross-over design, 13 participants (age 29 ± 9 years; 12 male) attended 2 sessions where experimental pain was induced by injecting hypertonic saline into either the first dorsal interosseous (FDI) muscle or infrapatellar fat pad at the knee, inducing a short-lasting pain experience scored on a numerical rating scale (NRS). Motor evoked potentials (MEPs) in response to transcranial magnetic stimulation were recorded in the FDI and vastus lateralis (VL) muscles before, during, and following pain. Hand and knee pain NRS scores were not significantly different. Hand pain elicited a short duration inhibition of the FDI MEPs (P < .0001) together with a facilitation of VL MEPs (P = .001) that outlasted the duration of pain. Knee pain elicited a short-duration facilitation of VL MEPs (P = .003) with no significant effect in the FDI MEPs (P = .46). The findings indicate a limb-specific corticomotor response to experimental pain that may be related to limb function. PERSPECTIVE: These data demonstrate the impact of acute, experimental pain on corticomotor excitability in the upper and lower limbs. This facilitates our understanding of the effect of pain on motor control of both local and distant muscles.

Impaired Regulation of Submaximal Force after ACL Reconstruction: Role of Muscle Spindles.

Ongoing motor deficits are routinely present following anterior cruciate ligament (ACL) reconstruction, including the ability to regulate muscle force. While such deficits are known, it is unclear why this occurs. The goal of the current study was to investigate the potential influence of muscle spindle input on submaximal force regulation and muscle activity at the knee in people following ACL reconstruction. Fourteen participants (8 female) who were 6-24 months post-ACL reconstruction and 15 control participants (8 female) undertook submaximal force matching and force modulation tasks before and after 20 min of vibration applied to the patella tendon. Across all tasks, the ACL reconstruction participants were poorer at force matching (P=0.007). The effect of vibration was not significant in either group for the force matching tasks (P=0.06), although there was a reduction in maximum voluntary contraction post-vibration in the control group (P<0.001). The ACL reconstruction group also showed evidence of greater activation of the medial hamstring muscles in comparison to controls (P=0.04). Individuals who have undergone ACL reconstruction have a diminished ability to accurately match and regulate submaximal muscle force, but this does not appear to be related to impaired muscle spindle input. Neuromuscular retraining programs that involve force regulation tasks may be necessary to optimize rehabilitation after ACL reconstruction.