The relationship between sustained hamstring pain and reorganisation of somatosensory representations: a randomised, controlled study.

ABSTRACT: Recurrent hamstring injuries are highly prevalent amongst sporting populations. It has been hypothesised that pain from an initial hamstring injury may induce reorganisation of somatosensory representations that could contribute to reinjury. However, because of the cross-sectional nature of existing research, it remains unknown whether somatosensory changes are a cause or effect of pain or if they are driven by other potentially confounding factors. Here, we explored the effect of experimentally induced sustained hamstring pain on tasks that interrogate somatosensory and spatial representations. Fifty healthy participants were randomly allocated to an experimental group that performed an eccentric exercise protocol on the right hamstring to induce delayed onset muscle soreness or a control group performing a repetition-matched concentric exercise protocol. The tactile cortical representation was assessed using two-point discrimination and tactile localisation, whereas the proprioceptive representation was assessed using a left-right judgement task. Peripersonal spatial representations were assessed using an auditory localisation task. Assessments were performed at baseline and day 2. No between-group differences in tactile acuity were observed. However, improvements in left-right judgments and worsening of auditory localisation occurred in the experimental group compared with the control group. This study provides preliminary evidence showing that somatosensory changes occur in response to sustained hamstring pain. Experimentally induced, sustained hamstring pain elicited enhancements in proprioceptive processing and deficits in peripersonal spatial processing, suggesting a shift in the allocation of attentional resources from the external (peripersonal) to internal (body) environment. These findings may hold important implications for reinjury risk and rehabilitation following hamstring pain.

Effects of weight loss through dietary intervention on pain characteristics, functional mobility, and inflammation in adults with elevated adiposity.

Background: The relationship between adiposity and pain is complex. Excess weight increases the risk for chronic musculoskeletal pain (CMP), driven by increased biomechanical load and low-grade systemic inflammation. Pain limits physical function, impacting energy balance contributing to weight gain. The primary aims of this study were to profile pain characteristics in participants with overweight or obesity and determine if weight loss through dietary-induced energy restriction, and presence of CMP, or magnitude of weight loss, was associated with changes in adiposity, pain, functional mobility, and inflammation. Methods: This was a secondary analysis of data from adults (25-65 years) with overweight or obesity (BMI 27.5-34.9 kg/m2) enrolled in a 3-month, 30% energy-restricted dietary intervention to induce weight loss (January 2019-March 2021). Anthropometric measures (weight, waist circumference and fat mass), pain prevalence, pain severity (McGill Pain Questionnaire, MPQ), pain intensity (Visual Analog Scale, VAS), functional mobility (timed up and go, TUG) and inflammation (high sensitivity C-Reactive Protein, hsCRP) were assessed at baseline and 3-months. Results: One hundred and ten participants completed the intervention and had weight and pain assessed at both baseline and 3-months. Participants lost 7.0 ± 0.3 kg, representing 7.9% ± 3.7% of body mass. At 3-months, functional mobility improved (TUG -0.2 ± 0.1 s, 95% CI -0.3, -0.1), but there was no change in hsCRP. Compared to baseline, fewer participants reported CMP at 3-months (n = 56, 51% to n = 27, 25%, p < 0.001) and presence of multisite pain decreased from 22.7% to 10.9% (p < 0.001). Improvements in anthropometric measures and functional mobility did not differ between those presenting with or without CMP at baseline. Improvements in pain were not related to the magnitude of weight loss. Conclusion: Weight loss was effective in reducing pain prevalence and improving functional mobility, emphasizing the importance of considering weight-loss as a key component of pain management. Clinical trial registration: identifier, ACTRN12618001861246.

The influence of threat on visuospatial perception, affordances, and protective behaviour: A systematic review and meta-analysis.

Perception has been conceptualised as an active and adaptive process, based upon incoming sensory inputs, which are modified by top-down factors such as cognitions. Visuospatial perception is thought to be scaled based on threat, with highly threatening objects or contexts visually inflated to promote escape or avoidance behaviours. This meta-analytical systematic review quantified the effect and evidence quality of threat-evoked visuospatial scaling, as well as how visuospatial scaling relates to affordances (perceived action capabilities) and behavioural avoidance/escape outcomes. Databases and grey literature were systematically searched inclusive to 10/04/24. Studies were assessed with a customised Risk of Bias form and meta-analysis was performed using a random-effects model. 12,354 records were identified. Of these, 49 experiments (n = 3027) were included in the review. There was consistent evidence that threat the of height influenced contextual perception (g = 0.66, 95% CI: 0.45, 0.88) and affordances (g = -0.43, 95% CI: -0.84, -0.03). Threatening objects were viewed as larger (g = 0.76, 95% CI: 0.26, 1.26) and as closer (g = 0.30, 95% CI: 0.17, 0.42). Bodily threat (pain) yielded conflicting effects on visuospatial perception/affordances. We conclude that threat may influence visuospatial perception and affordances. However, since behavioural measures were poorly reported, their relationship with visuospatial perception/affordances remains elusive.

The effectiveness of peer support interventions for community-dwelling adults with chronic musculoskeletal pain: a systematic review and meta-analysis of randomised trials.

ABSTRACT: This systematic review and meta-analysis critically examined the evidence for peer support interventions to reduce pain and improve health outcomes in community-dwelling adults with chronic musculoskeletal pain (PROSPERO CRD42022356850). A systematic search (inception-January 2023) of electronic databases and grey literature was undertaken to identify relevant randomised controlled trials, with risk of bias and GRADE assessments performed on included studies. Meta-analyses used a generic, inverse-variance, random-effects model, calculating mean difference (MD) or standardised mean difference (SMD). Of 16,445 records identified, 29 records reporting on 24 studies (n = 6202 participants) were included. All evidence had unclear/high risk of bias and low-very low certainty. Peer support interventions resulted in small improvements in pain (medium-term: MD -3.48, 95% CI -6.61, -0.35; long-term: MD -1.97, 95% CI -3.53, -0.42), self-efficacy (medium-term: SMD 0.26, 95% CI 0.16, 0.36; long-term: SMD 0.21, 95% CI 0.07, 0.36), and function (long-term: SMD -0.10, 95% CI -0.19, -0.00) relative to usual care and greater self-efficacy (medium-term: SMD 0.36, 95% CI 0.20, 0.51) relative to waitlist control. Peer support interventions resulted in similar improvement as active (health professional led) interventions bar long-term self-efficacy (MD -0.41, 95% CI -0.77, -0.05), which favoured active interventions. No point estimates reached minimal clinically important difference thresholds. Pooled health service utilisation outcomes showed unclear estimates. Self-management, quality of life, and social support outcomes had mixed evidence. Despite low-very low evidence certainty, peer support interventions demonstrated small improvements over usual care and waitlist controls for some clinical outcomes, suggesting that peer support may be useful as an adjunct to other treatments for musculoskeletal pain.

Age-related changes in responsiveness to non-invasive brain stimulation neuroplasticity paradigms: A systematic review with meta-analysis.

OBJECTIVES: We aimed to summarise and critically appraise the available evidence for the effect of age on responsiveness to non-invasive brain stimulation (NBS) paradigms delivered to the primary motor cortex. METHODS: Four databases (Medline, Embase, PsycINFO and Scopus) were searched from inception to February 7, 2023. Studies investigating age group comparisons and associations between age and neuroplasticity induction from NBS paradigms were included. Only studies delivering neuroplasticity paradigms to the primary motor cortex and responses measured via motor-evoked potentials (MEPs) in healthy adults were considered. RESULTS: 39 studies, encompassing 40 experiments and eight NBS paradigms were included: paired associative stimulation (PAS; n = 12), repetitive transcranial magnetic stimulation (rTMS; n = 2), intermittent theta burst stimulation (iTBS; n = 8), continuous theta burst stimulation (cTBS; n = 7), transcranial direct and alternating current stimulation ((tDCS; n = 7; tACS; n = 2)), quadripulse stimulation (QPS; n = 1) and i-wave periodic transcranial magnetic stimulation (iTMS; n = 1). Pooled findings from PAS paradigms suggested older adults have reduced post-paradigm responses, although there was considerable heterogeneity. Mixed results were observed across all other NBS paradigms and post-paradigm timepoints. CONCLUSIONS/SIGNIFICANCE: Whilst age-dependent reduction in corticospinal excitability is possible, there is extensive inter- and intra-individual variability both within and between studies, making it difficult to draw meaningful conclusions from pooled analyses.

People with painful knee osteoarthritis hold negative implicit attitudes towards activity.

ABSTRACT: Negative attitudes/beliefs surrounding osteoarthritis, pain, and activity contribute to reduced physical activity in people with knee osteoarthritis (KOA). These attitudes/beliefs are assessed using self-report questionnaires, relying on information one is consciously aware of and willing to disclose. Automatic (ie, implicit) assessment of attitudes does not rely on conscious reflection and may identify features unique from self-report. We developed an implicit association test that explored associations between images of a person moving/twisting their knee (activity) or sitting/standing (rest), and perceived threat (safe vs dangerous). We hypothesised that people with KOA would have greater implicit threat-activity associations (vs pain-free and non-knee pain controls), with implicit attitudes only weakly correlating with self-reported measures (pain knowledge, osteoarthritis/pain/activity beliefs, fear of movement). Participants (n = 558) completed an online survey: 223 had painful KOA (n = 157 female, 64.5 ± 8.9 years); 207 were pain free (n = 157 female, 49.3 ± 15.3 years); and 99 had non-KOA lower limb pain (n = 74 female, 47.5 ± 15.04 years). An implicit association between "danger" and "activity" was present in those with and without limb pain (KOA: 0.36, 95% CI 0.28-0.44; pain free: 0.13, 95% CI 0.04-0.22; non-KOA lower limb pain 0.11, 95% CI -0.03 to 0.24) but was significantly greater in the KOA group than in the pain free (P < 0.001) and non-KOA lower limb pain (P = 0.004) groups. Correlations between implicit and self-reported measures were nonsignificant or weak (rho = -0.29 to 0.19, P < 0.001 to P = 0.767). People with painful KOA hold heightened implicit threat-activity associations, capturing information unique to that from self-report questionnaires. Evaluating links between implicit threat-activity associations and real-world behaviour, including physical activity levels, is warranted.

Painful distortions: people with painful knee osteoarthritis have biased visuospatial perception of the environment.

ABSTRACT: Visuospatial perception is thought to be adaptive-ie, hills are perceived as steeper when capacity is low, or threat is high-guiding appropriate interaction with the environment. Pain (bodily threat) may similarly modulate visuospatial perception, with the extent of modulation influenced by threat magnitude (pain intensity, fear) and associated with behaviour (physical activity). We compared visuospatial perception of the environment between 50 people with painful knee osteoarthritis and 50 age-/sex-matched pain-free control participants using 3 virtual reality tasks (uphill steepness estimation, downhill steepness estimation, and a distance-on-hill measure), exploring associations between visuospatial perception, clinical characteristics (pain intensity, state and trait fear), and behaviour (wrist-worn accelerometry) within a larger knee osteoarthritis group (n = 85). People with knee osteoarthritis overestimated uphill (F1,485 = 19.4, P < 0.001) and downhill (F1,480 = 32.3, P < 0.001) steepness more so than pain-free controls, but the groups did not differ for distance-on-hill measures (U = 1273, P = 0.61). There was also a significant group x steepness interaction for the downhill steepness task (F4,480 = 3.11, P = 0.02). Heightened overestimation in people with knee osteoarthritis relative to pain-free controls increased as downhill slopes became steeper. Results were unchanged in a replication analysis using all knee osteoarthritis participants (n = 85), except the downhill steepness interaction was no longer significant. In people with knee osteoarthritis, higher state fear was associated with greater over-estimation of downhill slope steepness (rho = 0.69, P < 0.001), and greater visuospatial overestimation (distance-on-hill) was associated with lower physical activity levels (rho = -0.22, P = 0.045). These findings suggest that chronic pain may shift perception of the environment in line with protection, with overestimation heightened when threat is greater (steeper hills, more fearful), although impact on real-world behaviour is uncertain.

What I see and what I feel: the influence of deceptive visual cues and interoceptive accuracy on affective valence and sense of effort during virtual reality cycling.

Background: How we feel during exercise is influenced by exteroceptive (e.g., vision) and interoceptive (i.e., internal body signals) sensory information, and by our prior experiences and expectations. Deceptive visual cues about one's performance during exercise can increase work rate, without negatively impacting affective valence (good/bad responses) or perceived exertion. However, what is less understood is whether the perception of the exercise experience itself can be shifted, if work rate is held constant. Here we aimed to investigate whether deceptive vision-via illusory hills in a virtual reality (VR) cycling experience-alters affective valence and perceived exertion when physical effort is controlled. We also evaluated whether the accuracy with which one detects interoceptive cues influences the extent to which deceptive visual information can shift exercise experiences. Methods: A total of 20 participants (10 female; 30.2 ± 11.2 yrs) completed three VR cycling conditions each of 10-min duration, in a randomised, counterbalanced order. Pedal resistance/cadence were individualised (to exercise intensity around ventilatory threshold) and held constant across conditions; only visual cues varied. Two conditions provided deceptive visual cues about the terrain (illusory uphill, illusory downhill; resistance did not change); one condition provided accurate visual cues (flat terrain). Ratings of affective valence (Feeling Scale) and of perceived exertion (Borg's RPE) were obtained at standardised timepoints in each VR condition. Interoceptive accuracy was measured via a heartbeat detection test. Results: Linear mixed effects models revealed that deceptive visual cues altered affective valence (f2 = 0.0198). Relative to flat terrain, illusory downhill reduced affective valence (Est = -0.21, p = 0.003), but illusory uphill did not significantly improve affective valence (Est = 0.107, p = 0.14). Deceptive visual cues altered perceived exertion, and this was moderated by the level of interoceptive accuracy (Condition-Interoception interaction, p = 0.00000024, f2 = 0.0307). Higher levels of interoceptive accuracy resulted in higher perceived exertion in the illusory downhill condition (vs flat), while lower interoceptive accuracy resulted in lower perceived exertion in both illusory hill conditions (vs flat) and shifts of greater magnitude. Conclusions: Deceptive visual cues influence perceptual responses during exercise when physical effort does not vary, and for perceived exertion, the weighting given to visual exteroceptive cues is determined by accuracy with which interoceptive cues are detected. Contrary to our hypotheses, deceptive visual cues did not improve affective valence. Our findings suggest that those with lower levels of interoceptive accuracy experience most benefit from deceptive visual cues, providing preliminary insight into individualised exercise prescription to promote positive (and avoid negative) exercise experiences.

Item development and pre-testing of an Osteoarthritis Conceptualisation Questionnaire to assess knowledge and beliefs in people with knee pain.

Many people with osteoarthritis hold beliefs that physical activity is unhelpful or dangerous for their joints, despite high-level evidence suggesting otherwise. Recent advances in scientific understanding of osteoarthritis have led to new treatments that target an individual's understanding both of their condition and the importance of best-practice management strategies, such as physical activity. Conceptual change has been proposed as an important mechanism by which cognitive interventions, such as pain science education, may reduce pain and improve function. There are currently no specific assessments of osteoarthritis conceptualisation to determine the effectiveness of cognitive interventions in effecting conceptual change in people with knee osteoarthritis. Therefore, we aimed to develop an item bank, as the first phase of developing a questionnaire to assess people's conceptualisations about their knee osteoarthritis and the role of physical activity in managing their osteoarthritis. Using a guideline-informed mixed method design, a panel of experts identified domains relevant to conceptualisation about knee osteoarthritis and physical activity (knowledge, beliefs, understanding) based upon available evidence. The panel created 33 provisional items. Qualitative and quantitative pretesting were used to explore how people with knee osteoarthritis understood the provisional items. Eighteen people with knee osteoarthritis completed cognitive interviews about their comprehension of the wording/grammar of each provisional item. The provisional item bank was field tested with 100 people with knee osteoarthritis. Readability was adequate with a Flesch reading ease score of 57.7. Although 14.7% used the 'Strongly agree' response option, only 3.4% of responses used the 'Strongly disagree' option, suggesting possible response bias. Predictive quality testing identified relevant modifications to the questionnaire instructions. The panel of experts appraised the qualitative data to assess whether and how items should be modified to address the problems identified, resulting in a final item bank of 45 items that can be evaluated for psychometric properties in future research.

Mechanisms of education and graded sensorimotor retraining in people with chronic low back pain: a mediation analysis.

ABSTRACT: An improved understanding of the biopsychosocial influences that contribute to and maintain pain has promoted the development of new efficacious treatments for chronic low back pain (CLBP). This study aimed to investigate the mechanisms of a new treatment-education and graded sensorimotor retraining-on pain and disability. We conducted a preplanned causal mediation analysis of a randomized clinical trial which allocated 276 participants with CLBP to 12 weekly clinical sessions of education and graded sensorimotor retraining (n = 138) or a sham and attention control (n = 138). Outcomes were pain intensity and disability, both assessed at 18 weeks. Hypothesized mediators included tactile acuity, motor coordination, back self-perception, beliefs about the consequences of back pain, kinesiophobia, pain self-efficacy, and pain catastrophizing, all assessed at the end of treatment (12 weeks). Four of 7 mechanisms (57%) mediated the intervention effect on pain; the largest mediated effects were for beliefs about back pain consequences (-0.96 [-1.47 to -0.64]), pain catastrophizing (-0.49 [-0.61 to -0.24]), and pain self-efficacy (-0.37 [-0.66 to -0.22]). Five of 7 mechanisms (71%) mediated the intervention effect on disability; the largest mediated effects were for beliefs about back pain consequences (-1.66 [-2.62 to -0.87]), pain catastrophizing (-1.06 [-1.79 to -0.53]), and pain self-efficacy (-0.84 [-1.89 to -0.45]). When all 7 mechanisms were considered simultaneously, the joint mediation effect explained most of the intervention effect for both pain and disability. Optimizing interventions to target beliefs about the consequences of back pain, pain catastrophizing, and pain self-efficacy is likely to lead to improved outcomes for people with CLBP.

Get Your Head in the Game: A Replicated Single-Case Experimental Design Evaluating the Effect of a Novel Virtual Reality Intervention in People With Chronic Low Back Pain.

Chronic low back pain (CLBP) is a leading cause of disability worldwide. Contemporary treatment of CLBP is suboptimal, with small-moderate effect sizes and high relapse rates. Virtual reality (VR) is an increasingly accessible technology that can improve adherence to exercise programs through gamification. Using VR to facilitate exercise adherence and enjoyment may improve the clinical outcomes. This study aimed to evaluate the effects of a gamified VR graded activity intervention in people with CLBP, using commercially available and bespoke VR programs. A sequentially replicated, multiple-baseline, randomized AB single-case experimental design was undertaken in 10 people with CLBP. Outcomes were assessed daily and included pain intensity (primary) and pain catastrophizing, pain-related fear, and anxiety/worry (secondary). The effect of the intervention on the primary outcome was evaluated using a multilevel-model, nonparametric randomization test. The VR graded activity intervention resulted in a significant reduction in pain intensity (effect estimate = -1.0, standard error = .27, P < .0011) with 4 participants achieving ≥30% pain reduction (minimum important change). There was a significant effect of the intervention on pain catastrophizing but not pain-related fear or anxiety/worry measures. These findings provide preliminary support for a VR graded activity program to reduce pain in people with CLBP. PERSPECTIVE: This novel, VR graded activity intervention reduced pain intensity and catastrophizing in people with CLBP. The intervention also had high adherence and enjoyment. Given that this intervention involved 2 freely available VR programs, it can be easily translated into clinical practice.

The Foundations for Chronic Low Back Pain Management may Start in Early Life. Exploring the Role of Caregiver Parental Leave on Future Low Back Pain in the Offspring.

Chronic low back pain is difficult to treat and despite increased spending on health services, clinical outcomes for people with low back pain have not improved. Innovative, large scale initiatives seem necessary to stem the cost of low back pain. Psychological health contributes to the development and persistence of chronic low back pain and psychological interventions are important in the management of low back pain. Given the contribution of psychological health to low back pain development and management, it raises the question; can we support psychological health in later life by bolstering emotional development in early life, and reduce the burden of this common condition? Positive early life experiences, including those induced by extended paid parental leave, could bolster emotional development and support the psychological health necessary to manage low back pain in later life. We present the current state of evidence demonstrating the potential value of increasing support for parent-child relationships in early life to reduce the burden of low back pain in future generations. The current evidence is limited to cross-sectional associations, but strong preclinical data clearly shows the potential negative impacts of maternal separation on rodent pup health that compels consideration in human populations. PERSPECTIVE: The benefits stemming from enhanced child development include stable emotional foundations, possibly improving psychological health and low back pain management in the future. This perspective raises questions for future studies - within the context of low back pain, what ingredients bolster stable psychological health? And are these ingredients influenced by parental leave?

Safety and Adverse Events following Non-invasive Electrical Brain Stimulation in Stroke: A Systematic Review.

BACKGROUND: Noninvasive electrical stimulation (ES) could have therapeutic potential in stroke recovery. However, there is no comprehensive evaluation of adverse events. This study systematically searched the literature to document frequency and prevalence of adverse events. A secondary aim was to explore associations between adverse events and ES parameters or participant characteristics.Methods: Databases were searched for studies evaluating ES in adults with stroke. All included studies were required to report on adverse events. Extracted data were: (1) study design; (2) adverse events; (3) participant characteristics; (4) ES parameters. RESULTS: Seventy-five studies were included. Adverse events were minor in nature. The most frequently reported adverse events were tingling (37.3% of papers), burning (18.7%), headaches (14.7%) and fatigue (14.7%). Cathodal stimulation was associated with greater frequency of itching (p = .02), intensities of 1-2 mA with increased tingling (p = .04) and discomfort (p = .03), and current density <0.4mA/cm2 with greater discomfort (p = .03). Tingling was the most prevalent adverse event (18.1% of participants), with prevalence data not differing between active and control conditions (all p ≥ 0.37). Individual participants were more likely to report adverse events with increasing current density (r = 0.99, p = .001). Two severe adverse events were noted (a seizure and percutaneous endoscopic gastrostomy placement). CONCLUSION: ES appears safe in people with stroke as reported adverse events were predominantly minor in nature. An adverse events questionnaire is proposed to enable a more comprehensive and nuanced analysis of the frequency and prevalence of adverse events.

Suggestions in Hypnosis to Aid Pain Education (SHAPE) in People with Chronic Low-Back Pain: A Pilot Feasibility Randomized, Controlled Trial.

Chronic low back pain (CLBP) is a debilitating and burdensome condition, and new treatment strategies are needed. This study aimed to evaluate (1) the feasibility of undertaking a controlled clinical trial investigating a novel intervention for people with CLBP: hypnotically reinforced pain science education, and (2) the acceptability of the intervention as rated by participants. A priori feasibility and intervention acceptability criteria were set. Twenty participants with CLBP were recruited and randomized to receive: (1) hypnotically delivered pain science education that utilizes hypnotic suggestions to enhance uptake of pain science concepts; or (2) pain science education with progressive muscle relaxation as an attention control. Twenty participants were recruited, however, not solely from the hospital waitlist as intended; community sampling was required (13 hospital, 7 community). Most criteria were met in the community sample but not the hospital sample. Protocol modifications are needed before progressing to a full scale randomized controlled trial for hypnotically reinforced pain science education. Improvements in relevant secondary outcomes paired with moderate-high treatment acceptability ratings are promising.

Effect of Graded Sensorimotor Retraining on Pain Intensity in Patients With Chronic Low Back Pain: A Randomized Clinical Trial.

Importance: The effects of altered neural processing, defined as altering neural networks responsible for perceptions of pain and function, on chronic pain remains unclear. Objective: To estimate the effect of a graded sensorimotor retraining intervention (RESOLVE) on pain intensity in people with chronic low back pain. Design, Setting, and Participants: This parallel, 2-group, randomized clinical trial recruited participants with chronic (>3 months) nonspecific low back pain from primary care and community settings. A total of 276 adults were randomized (in a 1:1 ratio) to the intervention or sham procedure and attention control groups delivered by clinicians at a medical research institute in Sydney, Australia. The first participant was randomized on December 10, 2015, and the last was randomized on July 25, 2019. Follow-up was completed on February 3, 2020. Interventions: Participants randomized to the intervention group (n = 138) were asked to participate in 12 weekly clinical sessions and home training designed to educate them about and assist them with movement and physical activity while experiencing lower back pain. Participants randomized to the control group (n = 138) were asked to participate in 12 weekly clinical sessions and home training that required similar time as the intervention but did not focus on education, movement, and physical activity. The control group included sham laser and shortwave diathermy applied to the back and sham noninvasive brain stimulation. Main Outcomes and Measures: The primary outcome was pain intensity at 18 weeks, measured on an 11-point numerical rating scale (range, 0 [no pain] to 10 [worst pain imaginable]) for which the between-group minimum clinically important difference is 1.0 point. Results: Among 276 randomized patients (mean [SD] age, 46 [14.3] years; 138 [50%] women), 261 (95%) completed follow-up at 18 weeks. The mean pain intensity was 5.6 at baseline and 3.1 at 18 weeks in the intervention group and 5.8 at baseline and 4.0 at 18 weeks in the control group, with an estimated between-group mean difference at 18 weeks of -1.0 point ([95% CI, -1.5 to -0.4]; P = .001), favoring the intervention group. Conclusions and Relevance: In this randomized clinical trial conducted at a single center among patients with chronic low back pain, graded sensorimotor retraining, compared with a sham procedure and attention control, significantly improved pain intensity at 18 weeks. The improvements in pain intensity were small, and further research is needed to understand the generalizability of the findings. Trial Registration: ANZCTR Identifier: ACTRN12615000610538.

Key Learning Statements for Persistent Pain Education: An Iterative Analysis of Consumer, Clinician and Researcher Perspectives and Development of Public Messaging.

Over the last decade, the content, delivery and media of pain education have been adjusted in line with scientific discovery in pain and educational sciences, and in line with consumer perspectives. This paper describes a decade-long process of exploring consumer perspectives on pain science education concepts to inform clinician-derived educational updates (undertaken by the authors). Data were collected as part of a quality audit via a series of online surveys in which consent (non-specific) was obtained from consumers for their data to be used in published research. Consumers who presented for care for a persistent pain condition and were treated with a pain science education informed approach were invited to provide anonymous feedback about their current health status and pain journey experience 6, 12 or 18 months after initial assessment. Two-hundred eighteen consumers reported improvement in health status at follow-up. Results of the surveys from 3 cohorts of consumers that reported improvement were used to generate iterative versions of 'Key Learning Statements'. Early iteration of these Key Learning Statements was used to inform the development of Target Concepts and associated community-targeted pain education resources for use in public health and health professional workforce capacity building initiatives. PERSPECTIVE: This paper reflects an explicit interest in the insights of people who have been challenged by persistent pain and then recovered, to improve pain care. Identifying pain science concepts that consumers valued learning provided valuable information to inform resources for clinical interactions and community-targeted pain education campaigns.

Does who I am and what I feel determine what I see (or say)? A meta-analytic systematic review exploring the influence of real and perceived bodily state on spatial perception of the external environment.

Background: Bodily state is theorised to play a role in perceptual scaling of the environment, whereby low bodily capacity shifts visuospatial perception, with distances appearing farther and hills steeper, and the opposite seen for high bodily capacity. This may play a protective role, where perceptual scaling discourages engaging with the environment when capacity is low. Methodology: Our protocol was pre-registered via Open Science Framework (https://osf.io/6zya5/) with all amendments to the protocol tracked. We performed a systematic review and meta-analysis examining the role of bodily state/capacity on spatial perception measures of the environment. Databases (Medline, PsychINFO, Scopus, Embase, and Emcare) and grey literature were searched systematically, inclusive to 26/8/21. All studies were assessed using a customised Risk of Bias form. Standard mean differences and 95% CIs were calculated via meta-analysis using a random-effects model. Results: A total of 8,034 studies were identified from the systematic search. Of these, 68 experiments (3,195 participants) met eligibility and were included in the review. These were grouped into the following categories: fatigue; pain; age; embodiment; body size/body paty size; glucose levels; fitness; and interoception, and interoceptive accuracy. We found low level evidence (limited studies, high risk of bias) for the effect of bodily state on spatial perception. There was consistent evidence that both glucose manipulations and age influence spatial perception of distances and hills in a hypothesised direction (lower capacity associated with increased distance and hill steepness). Mixed evidence exists for the influence of external loads, embodiment, body/body-part size manipulations, pain, and interoceptive accuracy. Evidence for fitness and/or fatigue influencing spatial perception was conflicting; notably, methodological flaws with fitness and fatigue paradigms and heterogenous spatial perception measures may underlie null/conflicting results. Conclusion: We found limited evidence for bodily state influencing spatial perception of the environment. That all studies had high risk of bias makes conclusions about reported effects reflecting actual perceptual shifts (vs merely reflecting experimental demands or error due to inadequate study design) pre-emptive. Rigorous evaluation is needed to determine whether reported effects reflect more than bias (e.g., experimental demands, inadequate blinding). Future work using reliable measures of spatial perception, comprehensive evaluation of relevant confounders, and methodologically robust (and experimentally confirmed) bodily state experimental paradigms is warranted.

Reframe the pain: Divided attention and positive memory reframing to reduce needle pain and distress in children-A feasibility randomized controlled trial.

BACKGROUND: Negative experiences of needle procedures in childhood can lead to medical avoidance and vaccine hesitancy into adulthood. We evaluated the feasibility of two new interventions provided by clinical nurses to reduce the negative impact of vaccinations: divided attention (DA) and positive memory reframing (PMR). METHODS: Children (8-12 years) were randomized into four groups: usual care (UC), DA, PMR or combined (DA + PMR). To evaluate feasibility, we undertook in-depth analysis of video-recorded interventions, nurse experiences (phone interviews) and child/parent memory recall of interventions (phone interviews at 2 weeks post-vaccination). Key clinical outcomes included child and parent ratings of needle-related pain intensity and fear assessed at baseline, immediately post-vaccination and 2 weeks post-vaccination (recalled). RESULTS: A total of 54 child-parent dyads were screened, with 41 included (10/group, except PMR [n = 11]). The interventions were not always completed as intended: 10%-22% of participants received complete interventions and two had adverse events related to protocol breach. Preliminary within-group analyses showed no effects on child/parent pain ratings. However, children in DA + PMR had reduced recalled fear (p = 0.008), and PMR (p = 0.025) and DA + PMR (p = 0.003) had reduced fear of future needles. Parent ratings of child fear were also reduced immediately post-vaccination for UC (p = 0.035) and PMR (p = 0.035). CONCLUSIONS: The interventions were feasible, although enhanced nurse training is required to improve fidelity. Preliminary clinical results appear promising, particularly for reducing needle-related fear. PROTOCOL REGISTRATION: Protocol number ACTRN12618000687291 at ANZCTR.org.au SIGNIFICANCE: Two new nurse-led interventions to reduce negative impacts of vaccinations in children, divided attention and positive memory reframing, were feasible and may reduce needle-related fear. Nurses were able to deliver the interventions in various environments including non-clinical settings (schools). These interventions have potential to facilitate broader dissemination of vaccinations for children in a manner that minimizes distress.

Patient perspectives of pain and function after knee replacement: a systematic review and meta-synthesis of qualitative studies.

Introduction: Joint replacement surgery typically results in good clinical outcome, although some people experience suboptimal pain relief and functional improvement. Predicting surgical outcome is difficult. Objectives: There is merit in better understanding patients' perspectives of pain and function to identify avoidable problems perceived to contribute to their outcome, to inform prognostic expectations, and to identify potential cointerventions to sit alongside surgery that might mitigate pain/functional problems. Here, we aimed to synthesise the available literature exploring perspectives of people with knee osteoarthritis about their pain and function following joint replacement. Methods: Six electronic databases and 2 websites were searched. Two independent reviewers completed study inclusion, quality assessment, and data extraction. Data were iteratively synthesised using first-, second-, and third-order analyses. Results: Twenty-eight studies were included. Four themes were identified; perceptions of pain and function were inseparable. Theme 1 addressed experiences of recovery after surgery, which often differed from expectations. Theme 2 described the challenges of the pain experience and its functional impact, including the difficulty navigating medication use in context of personal beliefs and perceived stigma. Theme 3 articulated the toll of ongoing problems spanning pain-function-mood, necessitating the need to "endure." Theme 4 encompassed the importance of clinical/social interactions on mood and pain, with reports of concerns dismissed and practical support missing. Conclusions: Together, these findings show that numerous individual considerations beyond the technical aspects of surgery influence experiences of pain and function. A tailored approach addressing these considerations from the patient perspective could provide a basis for improved success of knee replacement surgery.