Facilitators and barriers to the implementation of pain neuroscience education in the current Lebanese physical therapist health care approach: a qualitative study.

PURPOSE: The purpose of this paper was first to gain an in-depth understanding of the barriers and facilitators to implementing the BPS model and pain neuroscience education in the current Lebanese physical therapy health care approach and explore its acceptability. METHOD: A qualitative semi-structured interview using purposive sampling was conducted with eight Lebanese physical therapists practising in different governorates. The transcribed text from the interviews was analyzed using inductive thematic analysis. RESULTS: Two topics were generated and constructed by the researchers: (1) "barriers to the implementation of pain neuroscience education, with subthemes including (a) "current health care approach," (b) "basic curriculum and continuing education," (c) "patients' barriers"; (2) "facilitators to the implementation of pain neuroscience education," with subthemes containing (a) "interest in the BPS model, (b) "therapeutic alliance," and (c) "motivation for future training on BPS approach." CONCLUSION: The analysis of the results showed that Lebanese physical therapists currently hold a strong biomedical view of chronic pain, assessment, and treatment. However, despite the presence of barriers and challenges, they are aware and open to consider the implementation and future training about the BPS model and pain neuroscience education in their approach.IMPLICATIONS FOR REHABILITATIONThe exploration of potential barriers and facilitators to the bio-psychosocial model and pain neuroscience education implementation may provide an opportunity for better development and design of a culturally sensitive pain neuroscience education material for Arab-speaking and Lebanese physical therapists.The exploration of barriers and facilitators to the implementation of pain neuroscience education will help to improve pain education and ensure better clinical pain management.The most important barriers were the dominant characteristic of the Lebanese physical therapist's health approach, which is focused on a biomechanically oriented model, and their lack of knowledge to approach chronic pain from a biopsychosocial perspective.

Sensory processing and central pain modulation in patients with chronic shoulder pain: A case-control study.

Chronicity and recurrence in musculoskeletal shoulder pain are highly prevalent and can possibly be attributed to the concept of central sensitization. Available studies suggest a role for central sensitization in explaining chronic shoulder pain, but so far a comprehensive quantitative sensory testing (QST) protocol has not been used. The aim of this study was to gain knowledge on sensory processing and central pain modulatory mechanisms in patients suffering from chronic shoulder pain using such a QST protocol. Fifty study participants, including chronic shoulder pain patients and healthy controls, underwent a standardized, comprehensive psychophysical testing procedure. A static adapted QST protocol (including pressure algometry, vibration and mechanical detection) was applied. Thereafter, all subjects underwent dynamic measures of temporal summation and conditioned pain modulation. Questionnaires assessing psychosocial factors were completed by each subject. No significant differences (P >= .05) were found between patients and controls based on pressure algometry, vibration detection, mechanical detection, temporal summation, and conditioned pain modulation. Moderate positive correlations (r = .5) were found between pressure pain thresholds (PPTs) and the amount of sports participation. Weak-to-moderate negative correlations (r = -.3 à -.5) were found between PPTs and psychosocial factors such as pain catastrophizing. Based on these findings, we can conclude that central sensitization is no characteristic feature in chronic musculo-skeletal shoulder pain but can be present in individual cases.

Barriers and facilitators of participation in sports: a qualitative study on Dutch individuals with lower limb amputation.

INTRODUCTION: Although individuals with lower limb amputation may benefit from participation in sports, less than 40% do so. AIM: To identify the barriers and facilitators that influence participation in sports for individuals with lower limb amputation. DESIGN: Qualitative study. PARTICIPANTS: Twenty six individuals with lower limb amputation, all originating from the Dutch provinces of Groningen and Drenthe, of which 13 athletes. METHODS: Semi-structured interviews were used to gather information. Following thematic analysis, emerging themes were organized in three categories Technical, Social and Personal. RESULTS: Sport was perceived as enjoyable activity that would help participants to become and stay healthy, improve the number of social contacts, reduce phantom pain and decrease daily tension. Inadequate facilities, problematic transportation, trivialization from others, poor health and lack of motivation or the lack of a sports partner were barriers commonly mentioned by non-athletes. Remarkably, while all athletes were successful prosthetic users, the majority chose to participate in sports for which prosthesis was neither required nor needed. CONCLUSIONS: Each individual with lower limb amputation needs to be counselled according to the barriers and facilitators he/she personally experiences. Athletes appeared to be more proactive in searching for a solution and also appeared less discouraged by failing.

Do patients with chronic patellar tendinopathy have an altered somatosensory profile? A Quantitative Sensory Testing (QST) study.

The prevalence of tendinopathies in sports is high. The etiology and pain mechanisms of tendinopathies are not completely understood. Currently, little is known whether, or to which degree, somatosensory changes within the nervous system may contribute to the pain in tendinopathies. We conducted a patient controlled study in which we used the standardized QST protocol developed by the German Research Network on Neuropathic Pain. This protocol consists of seven different tests that measures 13 somatosensory parameters and can be seen as the gold standard to measure somatosensory function. Twelve athletes with clinically diagnosed chronic patellar tendinopathy (PT) mean duration 30 months (range 6-120) and 20 controls were included in the study. In two of the 13 QST parameters namely Mechanical Pain Threshold (P < 0.05) and Vibration Disappearance Threshold (P < 0.5) injured athletes were significantly more sensitive for the applied stimuli. None of the athletes had signs of Dynamic Mechanical Allodynia. Reduced mechanical pain thresholds or pinprick allodynia reflects the involvement of central sensitization upon the myelinated (Aδ-fibre) nociceptive input. From this explorative study, we conclude that sensitization may play a prominent role in the pain during and after sports activity in patella tendinopathy patients.

A qualitative study on overuse injuries: the beliefs of athletes and coaches.

OBJECTIVES: Preventive approaches for overuse injuries in sports will be more successful when synchronised with athletes' and coaches' beliefs. We interviewed athletes and coaches in order to better characterize their beliefs about the definition of an overuse injury, as well as the intrinsic and extrinsic risk factors that underlie overuse injuries. DESIGN: Qualitative study using in-depth interviews in athletes and coaches of different sports. METHODS: Athletes who had experienced overuse injuries and coaches who trained athletes who had sustained overuse injuries from sports clubs were invited to participate through interview. We explored each participant's individual definition of an overuse injury and the beliefs concerning the intrinsic and extrinsic risk factors concerning overuse injuries were explored. RESULTS: After nine athletes and nine coaches, sample size saturation was confirmed. Athletes and coaches integrate somatic as well as psychological and sociological factors into the definition of and risk factors for overuse injuries. Intrinsic factors for an overuse injury were related to physical factors, technique, psychological factors and heredity. The extrinsic factors were related to situational, social and training factors, as well as the individual coach. CONCLUSIONS: Athletes and coaches have a holistic view on the definition of overuse injuries, and the intrinsic and extrinsic risk factors for overuse injuries. If preventive approaches for overuse injuries are developed and implemented, they should incorporate physical factors, as well as incorporate psychological and social factors. Based on the input of coaches and athletes, the latter are important risk factors for overuse injuries.

Is appreciation of written education about pain neurophysiology related to changes in illness perceptions and health status in patients with fibromyalgia?

OBJECTIVE: To investigate the appreciation of written education about pain neurophysiology in patients with fibromyalgia (FM) and its effects on illness perceptions and perceived health status. METHODS: A booklet explaining pain neurophysiology was sent to participants with FM. Appreciation was assessed with 10 questions addressing relevance (0-30) and reassurance (0-30). Illness perceptions, catastrophizing and health status were measured with the Revised Illness Perception Questionnaire (IPQ-R), the Pain Catastrophizing Scale (PCS) and the Fibromyalgia Impact Questionnaire (FIQ) at baseline (T0), after a 2-week control period (T1) and 6 weeks after the intervention (T2). RESULTS: Forty-one patients participated. Mean (SD) scores for relevance and reassurance were 21.6 (5.6) and 18.7 (5.7), respectively. Only illness coherence, emotional representations, pain and fatigue changed significantly between T0 and T2. Correlations between appreciation and changes in outcomes ranged between r=0.00 and r=0.34. CONCLUSIONS: Although a majority of subjects appreciated the written information, it did not have clinically relevant effects on illness perceptions, catastrophizing or impact of FM on daily life. PRACTICE IMPLICATIONS: Written education about pain neurophysiology is inadequate toward changing illness perceptions, catastrophizing or perceived health status of participants with FM; education should be incorporated into a broader multidisciplinary self-management program.

Illness perceptions in patients with fibromyalgia.

OBJECTIVE: Former studies in chronic diseases showed the importance of patients' beliefs and perceptions. The Revised Illness Perception Questionnaire was developed to assess these illness perceptions. Our goal was to investigate psychometric properties of the IPQ-R for Fibromyalgia Dutch language version (IPQ-R FM-Dlv) and to describe illness perceptions of participants with FM. METHODS: 196 patients completed the IPQ-R FM-Dlv. Internal consistency, domain structure and inter domain correlations were calculated and compared to the IPQ-R English language version. Scores were compared with chronic fatigue syndrome (CFS), rheumatoid arthritis (RA), and coronary heart disease (CHD). RESULTS: Most psychometric properties were comparable to those of the original IPQ-R. Participants showed a lack of understanding of their illness, expected their FM to be chronic and to have a lot of negative consequences on functioning. In 17 out of 24 domains significant differences were found between FM and CFS, RA, and CHD patients. CONCLUSION: The IPQ-R FM-Dlv showed acceptable psychometric properties, although some aspects need closer examination. Illness perceptions of FM patients on the Dutch questionnaire were non-comparable to CFS, RA, and CHD patients on the English questionnaire. PRACTICE IMPLICATIONS: The IPQ-R FM-Dlv can be used to assess illness perceptions of Dutch FM patients.

Measuring somatic symptoms with the CES-D to assess depression in cancer patients after treatment: comparison among patients with oral/oropharyngeal, gynecological, colorectal, and breast cancer.

There is a high prevalence of depression after cancer treatment. In the literature, several authors have raised questions about assessing somatic symptoms to explore depression after cancer treatment. These somatic sequelae are a consequence of cancer treatment and should cause higher depression rates in cancer patients. In this study, the Somatic domain on a depression questionnaire, the Center for Epidemiologic Studies-Depression scale (CES-D) was analyzed in different cancer patients after treatment, as compared with a control group. Data from 566 cancer patients (oral/oropharyngeal, gynecological, colorectal, and breast cancer) and 255 randomly chosen comparison patients were analyzed. The total score on the CES-D domain of Somatic Retarded Activity significantly differed between the cancer and comparison groups; but the cancer groups showed both less somatic morbidity (colorectal cancer) and more somatic morbidity (oral/oropharyngeal, breast) than the comparison group. In the analyses of the CES-D with and without the Somatic domain, the prevalence of depression symptoms with the Somatic domain is lower for the cancer groups. Authors conclude that cancer patients are not a homogenous group as regards somatic sequelae. Evidence for removing Somatic items from the CES-D for patients after cancer treatment was not confirmed.

Chronic pain in rehabilitation medicine.

In this paper the chronicity of pain in non-specific pain syndromes is discussed. Experts in the study of pain with several professional backgrounds in rehabilitation are the authors of this paper. Clinical experience and literature form the basis of the paper. Non-specific low back pain and Complex Regional Pain Syndrome type I (CRPS-I) are discussed in the light of chronic pain. Many definitions of chronic pain exist. Yellow flags are important factors to identify possible chronic pain. In the acute phase of a non-specific pain complaint one should try to identify possible psychosocial inciting risk factors. Behavioural and cognitive treatment seems to be effective for chronic pain patients.

Shoulder and neck morbidity in quality of life after surgery for head and neck cancer.

BACKGROUND: Quality of life has become a major issue in determining the outcome of treatment in head and neck surgery with curative intent. The aim of our study was to determine which factors in the postoperative care, especially shoulder and neck morbidity, are related to quality of life and how these outcomes compared between patients who had undergone surgery and a control group. METHODS: We analyzed physical symptoms, psychological symptoms, and social and functional well-being at least 1 year after surgery and evaluated the differences in quality of life between patients who had undergone head and neck surgery and a control group. RESULTS: Depression scores contributed significantly to all domains of quality of life. Reduced shoulder abduction, shoulder pain, and neck pain are related to several domains of quality of life. The patient group scored significantly worse for social functioning and limitations from physical problems but scored significantly better for bodily pain and health changes. CONCLUSION: Depression and shoulder and neck morbidity are important factors in quality of life for patients who have undergone surgery for head and neck cancer.

Shoulder complaints after nerve sparing neck dissections.

The purpose of the study was to analyse the prevalence of shoulder complaints after nerve sparing neck dissection at least 1 year after surgery, and to analyse the influence of radiation therapy on shoulder complaints. Patients were interviewed for shoulder complaints, and patients filled out the shoulder disability questionnaire to evaluate shoulder disability in daily activities. In total 137 patients; 51 after modified radical neck dissection (MRND), 21 after postero-lateral neck dissection (PLND), and 65 after supraomohyoid neck dissection (SOHND) were analysed. After MRND 33.3% of the patients experienced shoulder complaints, after PLND 66.7%, and after SOHND 20% of the patients experienced shoulder complaints. Type of neck dissection was significantly (P < 0.001) related to shoulder complaints. Outcome on the shoulder disability questionnaire also showed a significant (P < 0.01) difference in outcome for type of neck dissection. The prevalence of shoulder complaints after SOHND are low, and reduce disability in daily activities. Radiation therapy does not have a significant effect on shoulder complaints and disability.

[The sensitization model: a method to explain chronic pain to a patient]. / Het sensitisatiemodel: een methode om een patiënt uit te leggen wat chronische pijn is.

Chronic pain is pain without a clear somatic substrate. As a result, patients with chronic pain often do not receive a clear diagnosis following a medical examination. In many patients, having pain without a proper explanation or diagnosis induces stress and the urge to search elsewhere for explanations and treatments. There is growing evidence that many chronic-pain syndromes, such as chronic low-back pain, whiplash and fibromyalgia, share the same pathogenesis: sensitisation of pain-modulating systems in the central nervous system at both spinal and supraspinal level. This central sensitisation is facilitated by numerous factors that contribute to the maintenance of pain in a way that differs from individual to individual. How sensitisation may develop and persist as a result of medical, psychological and social factors calls for research from the perspective of a bio-psycho-social model. If sensitisation is used to explain chronic pain to a patient and the patient understands the relation beween pain and the factors that play a role in the maintenance of the pain, this can lead to acceptation of a treatment learning to cope with these factors.

Muscle strength in patients with chronic pain.

OBJECTIVE: To analyse the influence of chronic pain on muscle strength. DESIGN: Muscle strength of patients with unilateral nonspecific chronic pain, in an upper or lower limb, were measured according to a standardized protocol using a hand-held dynamometer. Before and after muscle strength measurement, a visual analogue scale for pain intensity was assessed. RESULTS: Forty patients were measured and the muscle strength of the painful side was 20-30% less than that of the nonpainful side. Strength reduction was seen in the whole limb. A significant correlation between pain intensity and reduced muscle strength in the painful limb existed for hip flexion, knee flexion, knee extension and three-point grip. CONCLUSIONS: A strength reduction of 20-30% in a painful limb seems to be 'normal' in chronic pain patients.

Shoulder complaints after neck dissection; is the spinal accessory nerve involved?

UNLABELLED: The purpose of the current study was to investigate the relation between shoulder morbidity (pain and range of motion), and the function of the spinal accessory nerve after neck dissection. Identifying dysfunction of the nerve gives insight in the mechanisms of post-operative shoulder complaints. In total 112 patients after neck dissection (73 males/39 females), mean (SD) age 61 (13) years, participated in the study. The mean duration of follow up was 3 (2) years. Five patients had radical, 43 modified radical, 48 supraomohyoid, and 16 posterolateral neck dissection. Thirty-nine complained of shoulder pain of whom 20 (51%) had dysfunction of the spinal accessory nerve, and 19 (49%) did not. In total 29 patients (26%) had dysfunction of the spinal accessory nerve of whom 20 (69%) had shoulder pain. Shoulder pain was significantly related to dysfunction of the nerve (P < 0.001). Twenty-three patients had a difference in active range of motion in shoulder abduction of > or =40 degrees, of whom 22 (96%) had dysfunction of the nerve. A difference in active shoulder abduction of > or =40 degrees was significantly related to loss of function of the spinal accessory nerve (P < 0.001). CONCLUSION: Shoulder pain after neck dissection can only be attributed to dysfunction of the spinal accessory nerve in about 50%. If patients experience shoulder pain after neck dissection examination of the trapezius muscle and active bilateral abduction of the shoulder should be made to find out if the spinal accessory nerve is involved.