Person-centred management of upper limb complex regional pain syndrome: an integrative review of non-pharmacological treatment.

Introduction: Complex Regional Pain Syndrome (CRPS) is most common in the upper limb and associated with high disability. The purpose of this review was to critically appraise and synthesise literature exploring non-pharmacological treatment for upper limb CRPS, to guide upper-limb-specific management. Methods: Using an integrative review methodology, 13 databases were searched to identify all published studies on non-pharmacological management of upper limb CRPS. The Crowe Critical Appraisal Tool was used to provide quality ratings for included studies, and analysis employed a qualitative descriptive approach. Results: From 236 abstracts reviewed, 113 full texts were read, and 38 articles selected for data extraction. Designs included single case (n = 14), randomised controlled trial (n = 8), prospective cohort (n = 8), case series (n = 4), retrospective (n = 3), and mixed methods (n = 1). Interventions were categorised as sensory retraining (n = 13), kinesiotherapy (n = 7), manual therapies (n = 7), physical modalities (n = 6), and interdisciplinary treatment programmes (n = 5). All studies measured pain intensity, and most (n = 24) measured physical parameters such as strength, movement, or perceptual abilities. Few measured patient-rated function (n = 13) or psychological factors (n = 4). Quality ratings ranged from 30% to 93%, with a median of 60%. Conclusion: Methodological quality of non-pharmacological treatment approaches for upper limb CRPS is overall poor. Movement, desensitisation, and graded functional activity remain the mainstays of intervention. However, despite the impact of CRPS on wellbeing and function, psychological factors and functional outcomes are infrequently addressed. Further robust research is required to determine which aspects of treatment have the greatest influence on which symptoms, and when and how these should be introduced and progressed.

Experiences of diagnosis and treatment for upper limb Complex Regional Pain Syndrome: a qualitative analysis.

INTRODUCTION: Complex Regional Pain Syndrome (CRPS) most frequently affects the upper limb, with high associated disability. Delays to diagnosis and appropriate treatment can adversely impact prognosis and quality of life, but little is known about the healthcare experiences of people with CRPS. This study aimed to explore lived experiences of diagnosis and treatment for people with upper limb CRPS. METHODS: Participants were recruited through online support groups and multiple public and private healthcare settings in the Greater Wellington Region, New Zealand. Semi-structured interviews were conducted with participants who had experienced upper limb CRPS for more than three months and less than three years. Interviews were transcribed verbatim and analysed using reflexive thematic analysis. RESULTS: Thirteen participants (11 female, 2 male) aged between 43 and 68 years were interviewed. Duration of CRPS ranged from 7 months to 2.5 years. Five themes were identified. Participants initially engaged in healthcare out of a desire to return to being the person they were before having CRPS. Three interacting experiences epitomised the overall healthcare experience: (1) not knowing what is going on, (2) not being taken seriously, and (3) healthcare as adding another layer of load. Meanwhile, participants used multiple approaches in an attempt to not let CRPS stop them from continuing to live their lives. CONCLUSIONS: Participants in this study felt that credible information, validation, and simplification from healthcare providers and systems would support their process of navigating towards a meaningful life and self-concept in the presence of CRPS.

Features and methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system: a Delphi expert consensus study.

ABSTRACT: Classification of musculoskeletal pain based on underlying pain mechanisms (nociceptive, neuropathic, and nociplastic pain) is challenging. In the absence of a gold standard, verification of features that could aid in discrimination between these mechanisms in clinical practice and research depends on expert consensus. This Delphi expert consensus study aimed to: (1) identify features and assessment findings that are unique to a pain mechanism category or shared between no more than 2 categories and (2) develop a ranked list of candidate features that could potentially discriminate between pain mechanisms. A group of international experts were recruited based on their expertise in the field of pain. The Delphi process involved 2 rounds: round 1 assessed expert opinion on features that are unique to a pain mechanism category or shared between 2 (based on a 40% agreement threshold); and round 2 reviewed features that failed to reach consensus, evaluated additional features, and considered wording changes. Forty-nine international experts representing a wide range of disciplines participated. Consensus was reached for 196 of 292 features presented to the panel (clinical examination-134 features, quantitative sensory testing-34, imaging and diagnostic testing-14, and pain-type questionnaires-14). From the 196 features, consensus was reached for 76 features as unique to nociceptive (17), neuropathic (37), or nociplastic (22) pain mechanisms and 120 features as shared between pairs of pain mechanism categories (78 for neuropathic and nociplastic pain). This consensus study generated a list of potential candidate features that are likely to aid in discrimination between types of musculoskeletal pain.

Evaluating sensory profiles in nociplastic chronic low back pain: a cross-sectional validation study.

BACKGROUND: Sensory profiles (SPs) may be useful in classifying patients based on sensory sensitivity and behavioral responses to stimuli to develop personalized treatments for nonspecific chronic low back pain (CLBP). The Adolescent/Adult Sensory Profile (AASP) identifies four sensitivity and behavioral response-related quadrants: Sensory Sensitive, Sensation Avoiding, Low Registration, and Sensation Seeking. It is an appropriate questionnaire for evaluating SPs; however, it has not been validated in CLBP. OBJECTIVES: To assess the internal consistency, test-retest reliability, agreement, and construct validity of the AASP in a CLBP population with nociplastic pain in primary care physiotherapy. DESIGN: Two evaluations were performed at a 2-week interval in this non-experimental cross-sectional study. PARTICIPANTS: Patients with CLBP. METHODS: Questionnaires were used to compare outcomes with the AASP. Reliability was evaluated by assessing internal consistency and test-retest reliability. Construct validity was evaluated in response to the a priori hypothesis. RESULTS: Ninety patients with CLBP were included. Internal consistency was excellent for all SPs (Cronbach's alpha, 0.91-0.92). Test-retest reliability Intraclass Correlation Coefficient (ICC (3,2)) 0.82-0.87, for the SPs (95% CI 0.74-0.91, p< .001). Construct validity correlated positively with Low Registration, Sensory Sensitive, and Sensation Avoiding and negatively with Sensation Seeking. CONCLUSION: The AASP is suitable for evaluating SPs in primary care CLBP patients.

Validity of the Ages and Stages Questionnaire to identify young children with gross motor difficulties who require physiotherapy assessment.

AIM: To determine if the Ages and Stages Questionnaire, Third Edition Gross Motor domain (ASQ-3-GM) score is predictive of motor performance on the Alberta Infant Motor Scale (AIMS) and/or Neurological, Sensory, Motor, Developmental Assessment (NSMDA). METHOD: This was a cross-sectional study involving analysis of a 1-year consecutive clinical sample of data obtained from children attending a specialist public outpatient service. Participants were 84 children aged 0 to 5 years (mean age 24.9mo, SD 18.4mo; 50 males, 34 females) referred for physiotherapy assessment of gross motor skills in a tertiary child development service. Parents completed the ASQ-3 questionnaire and children were assessed using the AIMS (if aged 0-18mo) and/or NSMDA (all children). To determine possible relationships between ASQ-3-GM scores with AIMS and NSMDA scores, we calculated Spearman's rank correlation coefficients. To determine validity of the ASQ-3-GM 'refer for further assessment' ('refer') cut-off score to identify gross motor difficulties we calculated frequency distributions and crosstab analyses. RESULTS: ASQ-3-GM scores correlated with AIMS centile rank (r=0.697, p<0.001) and NSMDA motor performance classification (r=-0.548, p<0.001). The ASQ-3-GM 'refer' cut-off had 77% sensitivity, 91% specificity, and 95% positive predictive value (PPV) to identify children that scored ≤10th centile on the AIMS and 57% sensitivity, 92% specificity, and 97% PPV to identify children with at least minimal dysfunction on the NSMDA. INTERPRETATION: The ASQ-3-GM 'refer' cut-off score is a valid predictor of gross motor difficulties in young children. WHAT THIS PAPER ADDS: The Ages and Stages Questionnaire, Third Edition Gross Motor domain (ASQ-3-GM) score is valid to identify gross motor difficulties in young children. The ASQ-3-GM 'refer' cut-off had 95% positive predictive value (PPV) for children that scored ≤10th centile on the Alberta Infant Motor Scale. The ASQ-3-GM 'refer' cut-off had 97% PPV for at least minimal dysfunction on the Neurological, Sensory, Motor, Developmental Assessment.

Validez del Cuestionario de Edades y Etapas para identificar a niños pequeños con dificultades motoras gruesas que requieren evaluación de fisioterapia OBJETIVO: Determinar si el puntaje del Cuestionario de Edades y Etapas, dominio de Motricidad Gruesa de la Tercera Edición (ASQ-3-GM) es predictivo del rendimiento motor en la Escala Motora Infantil de Alberta (AIMS) y / o Evaluación Neurológica, Sensorial, Motora y de Desarrollo (NSMDA) ) MÉTODO: Este fue un estudio transversal que incluyó el análisis de una muestra clínica consecutiva de 1 año de datos obtenidos de niños que asistían a un servicio público ambulatorio especializado. Los participantes fueron 84 niños de 0 a 5 años (edad media 25m, DE 18m; 50 varones, 34 mujeres) remitidos para evaluación de fisioterapia de habilidades motoras gruesas en un servicio de desarrollo infantil de tercer nivel. Los padres completaron el cuestionario ASQ-3 y los niños fueron evaluados utilizando el AIMS (si tenían entre 0 y 18 meses) y / o NSMDA (todos los niños). Para determinar las posibles relaciones entre las puntuaciones ASQ-3-GM con las puntuaciones AIMS y NSMDA, calculamos los coeficientes de correlación de rango de Spearman. Para determinar la validez del ASQ-3-GM "remítase a una puntuación de corte de evaluación adicional" ("refiérase") para identificar dificultades motoras graves, calculamos distribuciones de frecuencia y análisis de tabla cruzada. RESULTADOS: Las puntuaciones ASQ-3-GM se correlacionaron con el rango de percentiles AIMS (r = 0.697, p <0,001) y la clasificación de rendimiento motor NSMDA (r = -0,548, p <0,001). El límite de 'referencia' ASQ-3-GM tenía 77% de sensibilidad, 91% de especificidad y 95% de valor predictivo positivo (VPP) para identificar a los niños que obtuvieron ≤10 percentil en el AIMS y 57% de sensibilidad, 92% de especificidad, y 97% de VPP para identificar a niños con disfunción mínima en el NSMDA. INTERPRETACIÓN: La puntuación de corte ASQ-3-GM 'referido' es un predictor válido de dificultades motoras gruesas en niños pequeños.

Validade do Questionário Idades e Fases para identificar crianças pequenas com dificuldades motoras que precisam de avaliação fisioterapêutica OBJETIVO: Determinar se a pontuação no Questionário de Idades e Fases, Terceira edição domínio Motor Grosso (ASQ-3-MG) é preditiva do desempenho moor segundo a Escala Motora Infantil de Alberta (AIMS) e /ou da Avaliação do Desenvolvimento Neurológico, Sensorial e Motor (NSMDA). MÉTODO: Este foi um estudo transversal envolvendo análise por um ano consecutivo de uma amostra clínica de dados obtidos de crianças frequentando um serviço ambulatorial especializado público. Participantes foram 84 crianças com idades de 0 a 5 anos (média de idade 25m, DP 18m; 50 do sexo masculino, 34 do sexo feminino) encaminhados para avaliação de fisioterapia das habilidades motoras grossas em um serviço terciário de desenvolvimento infantil. Os pais completaram o questionário ASQ-3 e as crianças foram avaliadas com a AIMS (se idade de 0-18m) e/ou NSMDA (todas as crianças). Para determinar possíveis relações entre escores ASQ-3-MG com escores AIMS e NSMDA, calculamos coeficientes de correlação de Spearman. Para determinar a validade do escore de corte do ASQ-3-MG para 'encaminhar para melhor avaliação' ('encaminhar) em identificar dificuldades motoras grossas, calculamos distribuições de frequências e análises cruzadas. RESULTADOS: Os escores ASQ-3-MG se correlacionaram com os percentis AIMS (r=0,697, p<0,001) e a classificação do desempenho motor segundo a NSMDA (r=-0,548, p<0,001). O escore de corte do ASQ-3-MG 'encaminhar' teve 77% de sensibilidade, 91% de especificidade , e 95% de valor preditivo positivo (VPP) para identificar crianças com percentil ≤10º na AIMS e 57% de sensibilidade, 92% de especificidade, e 97% VPP para identificar crianças com disfunção pelo menos mínima no NSMDA. INTERPRETAÇÃO: O escore de corte do ASQ-3-GM 'encaminhar' é um preditor válido de dificuldades motoras em crianças pequenas.

Using cannabis for pain management after spinal cord injury: a qualitative study.

Study design: A descriptive qualitative study. Objectives: To explore why individuals with spinal cord injury (SCI) choose to use cannabis to manage their pain and their experiences in doing so. Setting: Community-dwelling adults with SCI in New Zealand. Methods: Semi-structured interviews were conducted with individuals who had a SCI, experienced pain, and self-reported use of cannabis to manage their pain. Interviews were recorded, transcribed, and subject to thematic analysis. Results: Eight individuals participated in this study. We interpreted six themes that captured the participants' perspectives regarding their choice to, and perceptions of, using cannabis to manage SCI pain. Participants were motivated to use cannabis when other pain management strategies had been ineffective and were well-informed, knowledgeable cannabis consumers. Participants reported cannabis reduced their pain quickly and enabled them to engage in activities of daily living and participate in life roles without the drowsiness of traditional prescribed pain medication. Despite the positive aspects, participants were concerned about the irregularity of supply and inconsistent dosage. Conclusions: Findings show that cannabis is used to reduce pain after SCI and enable increased community participation. Findings suggest that future studies examining the efficacy of cannabinoids in managing pain include function and participation outcome measures rather than solely focusing on measuring pain intensity. Focusing on meaningful outcomes may contribute to a greater understanding of the experiences of people with SCI.