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.

Evaluating the effectiveness of patient tailored treatment for patients with non-specific low back pain: A systematic review.

OBJECTIVE: This systematic review summarizes the relevant literature on the effectiveness of tailored interventions in non-specific low back pain (NSLBP). METHODS: The search strategy has been executed in December 2019 in the electronic databases PubMed, Web of Science and Embase. Study selection, data extraction and quality assessment were done independently by two authors. RESULTS: A total six eligible studies were identified. Five out of six articles used a classification system to subgroup patients. All active patient tailored interventions had similar or better results than the non-patient tailored interventions, most importantly on pain (short- and mid-term, not for long term follow-up). Two motor control interventions revealed sustained or increased effects at 12 months follow-up for disability. For cost-effectiveness, medication use and work absenteeism, results were inconclusive. Global rating of change evaluation confirmed significant between-group results at 10 weeks to 4 months follow-up, but results were not maintained at 12-month evaluation. DISCUSSION & CONCLUSION: Our findings support the preliminary evidence for the use of patient tailored treatment for reductions in pain and disability. However, our results are of very low to moderate quality evidence and the observed effects strongly depend on the subgroups and the chosen interventions. More high-quality RCT's with homogenous designs and larger sample sizes are needed.

Do sociodemographic features, pain sensitivity or pain catastrophizing relate to clinic-based adherence to physiotherapy in people suffering from chronic spinal pain? Secondary analysis of a randomized clinical trial.

PURPOSE: Examining whether socio-demographic variables, pain or functionality are related to the degree of clinic-based therapy adherence in patients suffering from nonspecific chronic spinal pain (nCSP). DESIGN: Secondary analysis of a randomized clinical trial. SETTING: University hospital of Ghent and Brussels. METHODS: Dutch speakers, 18-65 years old, experiencing nCSP for at least 3 months. 120 participants were randomly allocated to two interventional groups, of which 94 completed all therapy sessions. MAIN OUTCOME MEASURES: Degree of clinic-based adherence, defined as the amount of completed therapy sessions. RESULTS: Demographic data (sex, age or education) were not significantly associated with adherence in the total sample or the neuroscience group. For the traditional physiotherapy group, educational level was associated with attendance of at least 50% of the therapy sessions. Regarding pain-, belief- and function-related measures, only the association between change in kinesiophobia and adherence was significant for the traditional physiotherapy group. CONCLUSIONS: Factors related to therapy adherence in the total group or the neuroscience group could not be found. Educational level and change in kinesiophobia were however related to therapy adherence in the traditional physiotherapy group.

Differences in white matter structure and cortical thickness between patients with traumatic and idiopathic chronic neck pain: Associations with cognition and pain modulation?

Brain alterations are hypothesized to be present in patients with chronic whiplash-associated disorders (CWAD). The aim of this case-control study was to examine alterations in cortical thickness and white matter (WM) structure, and the presence of brain microhemorrhages in a patient group encountering chronic neck pain of traumatic origin (i.e., CWAD) when compared with a patient group characterized by nontraumatic chronic neck pain [i.e., chronic idiopathic neck pain (CINP)], and healthy controls. Furthermore, we aimed to investigate associations between brain structure on one hand and cognitive performance and central sensitization (CS) on the other hand. T1-weighted, diffusion-weighted and T2*-weighted magnetic resonance images of the brain were acquired in 105 women (31 controls, 37 CINP, 37 CWAD) to investigate regional cortical thickness, WM structure, and microhemorrhages, respectively. Next, cognitive performance, and CS encompassing distant hyperalgesia and conditioned pain modulation (CPM) efficacy were examined. Cortical thinning in the left precuneus was revealed in CWAD compared with CINP patients. Also, decreased fractional anisotropy, together with increased values of mean diffusivity and radial diffusivity could be observed in the left cingulum hippocampus and tapetum in CWAD compared with CINP, and in the left tapetum in CWAD patients compared with controls. Moreover, the extent of WM structural deficits in the left tapetum coincided with decreased CPM efficacy in the CWAD group. This yields evidence for associations between decreased endogenous pain inhibition, and the degree of regional WM deficits in CWAD. Our results emphasize the role of structural brain alterations in women with CWAD compared with CINP.

[Orthopaedic manual therapy : definition, characteristics and update on the situation in Belgium]. / La thérapie manuelle orthopédique : définition, caractéristiques et mise au point sur la situation en Belgique.

Although orthopaedic manual therapy (OMT) has existed for decades, and although a recent Belgian Royal Decree, published in 2014, recognized it as a particular professional qualification in physiotherapy for the treatment of neuromusculoskeletal dysfunctions, OMT remains little known by patients, but also by healthcare professionals. Yet, this professional qualification, based on clinical reasoning, using highly specific treatments, guided by the best available scientific and clinical evidence and the specific biopsychosocial characteristics of each patient, is the subject of a growing number of scientific studies pointing out its effectiveness. This article summarizes the knowledge related to OMT (definition, history, characteristics, techniques, indications, access and reimbursement) and describes its situation in Belgium.

Bien que la thérapie manuelle orthopédique (TMO) existe depuis des décennies et qu'un récent arrêté royal belge reconnaissant cette discipline comme une qualification professionnelle particulière en kinésithérapie pour la prise en charge des troubles neuro-musculo-squelettiques ait été publié en 2014, la TMO demeure méconnue des patients, mais également du monde médical. Pourtant, cette discipline, basée sur un raisonnement clinique, utilisant des approches thérapeutiques hautement spécifiques guidées par les meilleures évidences scientifiques et cliniques disponibles ainsi que par la spécificité biopsychosociale propre à chaque patient, fait l'objet d'un nombre croissant d'études scientifiques mettant en évidence son intérêt. Cet article vise à synthétiser les connaissances relatives à la TMO (sa définition, son historique, ses caractéristiques, ses techniques, ses indications, son accès et son remboursement, ainsi que son enseignement) en décrivant la situation en Belgique.

Does muscle morphology change in chronic neck pain patients? - A systematic review.

BACKGROUND: Neck pain is a common disabling worldwide health problem with a high socio-economic burden. Changes underlying the transition to, or the maintenance of a chronic state are still barely understood. Increasing evidence suggests that morphological muscle changes, including changes in cross-sectional area (CSA) or fatty infiltration, play a role in chronic neck pain. However, a structured overview of the current evidence of morphological changes is lacking. OBJECTIVE: To systematically review the morphological muscle changes in patients with chronic neck pain, including those with whiplash-associated disorders (WAD) and chronic idiopathic neck pain. STUDY DESIGN & METHODS: A systematic review using the PRISMA-guidelines. RESULTS: Fourteen of 395 papers were included after extensive screening. Most studies were of moderate methodological quality. A higher CSA was found in all flexor muscles in both patients with WAD and patients with chronic idiopathic neck pain, except for the deeper flexor muscles in patients with chronic idiopathic neck pain. The cervical extensor muscles show an increased CSA at the highest cervical segments in patients with WAD, while most studies in patients with chronic idiopathic neck pain report a decreased CSA in all extensor muscles. Fatty infiltration, which could be accountable for an increased CSA, of both cervical extensors and flexors seems to occur only in patients with WAD. CONCLUSION: Some evidence is available for changes in muscle morphology, however more high quality prospective and cross-sectional research is needed to confirm these changes and to identify potential underlying causes that need yet to be discovered.

Identifying prognostic factors predicting outcome in patients with chronic neck pain after multimodal treatment: A retrospective study.

OBJECTIVES: This study was conducted to identify possible prognostic factors to predict drop-out and favorable outcome in patients following a multimodal treatment program at an outpatient rehabilitation clinic. METHODS: A retrospective cohort study was conducted on 437 patients with chronic neck pain involved in an exercise-based rehabilitation program of an outpatient rehabilitation center between January 2008 and November 2011. Prognostic factors were analyzed through a univariate and a multivariate logistic regression analysis. RESULTS: Multivariate logistic regression revealed that a higher age (OR=0.960), presence of headache (OR=0.436) or low back pain (OR=0.525), and having low levels of depression (OR=1.044) increase the odds to complete the multimodal treatment program. A high NDI-score (OR=0.945), a high NRS-score for pain in the upper extremities (OR=0.862), a low NRS score for pain in the neck (OR=1.372), and a trauma in the patient's history (OR=0.411) decrease the odds of having a favorable outcome after the given treatment program. CONCLUSION: It is important to assess these prognostic factors as they may help therapists to identify patients with a good prognosis or patients at risk. For those at risk, this would allow the treatment approach to be redirected to address their specific needs.

Articular dysfunction patterns in patients with mechanical low back pain: A clinical algorithm to guide specific mobilization and manipulation techniques.

Recent systematic reviews have demonstrated reasonable evidence that lumbar mobilization and manipulation techniques are beneficial. However, knowledge on optimal techniques and doses, and its clinical reasoning is currently lacking. To address this, a clinical algorithm is presented so as to guide therapists in their clinical reasoning to identify patients who are likely to respond to lumbar mobilization and/or manipulation and to direct appropriate technique selection. Key features in subjective and clinical examination suggestive of mechanical nociceptive pain probably arising from articular structures, can categorize patients into distinct articular dysfunction patterns. Based on these patterns, specific mobilization and manipulation techniques are suggested. This clinical algorithm is merely based on empirical clinical expertise and complemented through knowledge exchange between international colleagues. The added value of the proposed articular dysfunction patterns should be considered within a broader perspective.

Changes in microcirculation of the trapezius muscle during a prolonged computer task.

The aim of this study is to investigate if there is a change in oxygen saturation and blood flow in the different parts of the trapezius muscle in office workers with and without trapezius myalgia during a standardized computer task. Twenty right-handed office workers participated; ten were recruited based on pain in the trapezius and ten as matching controls. Subjects performed a combination of typing and mousing tasks for 60 min at a standardized workstation. Muscle tissue oxygenation and blood flow data were collected from the upper trapezius (UT), the middle trapezius (MT) and the lower trapezius (LT), both on the left and right side at seven moments (at baseline and every tenth minute during the 1-h typing task) by use of the oxygen to see device. In all three parts of the trapezius muscle, the oxygen saturation and blood flow decreased significantly over time in a similar pattern (p < 0.001). Oxygenation of the left and right UT was significantly higher compared to the other muscle parts (p < 0.001). Oxygen saturation for the MT was significantly lower in the cases compared to the control group (p = 0.027). Blood flow of the UT on the right side was significantly lower than the blood flow on the left side (p = 0.026). The main finding of this study was that 1 h of combined workstation tasks resulted in decreased oxygen saturation and blood flow in all three parts of the trapezius muscle. Future research should focus on the influence of intervention strategies on these parameters.

Functional reorganization of cervical flexor activity because of induced muscle pain evaluated by muscle functional magnetic resonance imaging.

There is mounting evidence of an association between chronic neck pain and impaired cervical flexor muscle performance. It is likely that the deep cervical flexors demonstrate changes very early after the onset of pain, but evidence is currently lacking. This study investigated the effect of experimental neck muscle pain on the activation of the cervical flexor muscles during the performance of craniocervical flexion (CCF) by use of muscle functional magnetic resonance imaging. Activity of the longus colli (Lco), longus capitis (Lca) and sternocleidomastoid (SCM) muscles were investigated bilaterally and at three cervical levels (C0-C1, C2-C3 and C6-C7) in 14 healthy subjects. Measurements were performed at rest and after the performance of CCF without and with induced pain of the upper trapezius (intramuscular injection of hypertonic saline). In the non-pain condition, the Lca (p = 0.005) and Lco (p = 0.029) were significantly more active during CCF compared to SCM. In the pain condition, the activity of the Lco and Lca was reduced bilaterally and at multiple levels (p ≤ 0.009), whereas the left SCM showed increased activity at only the C6-C7 level (p ≤ 0.001). The results suggest that local excitation of nociceptive afferents causes an immediate reorganization of the cervical flexor muscle activity similar to that identified in clinical populations.

The effect of unilateral muscle pain on recruitment of the lumbar multifidus during automatic contraction. An experimental pain study.

Changes in control of the multifidus muscle are a likely contributor to low back pain (LBP), however, the underlying mechanisms of these changes are not well understood. To date it remains uncertain if pain has a selective effect on the multifidus muscles, in line with the observations of the selective changes in structure in acute LBP, or a more generalized effect. The objective of this study is to help to elucidate whether acute unilateral muscle pain alters the activation of the multifidus specific at the level and side of the pain or has a more widespread effect. An experimental pain protocol using hypertonic saline was applied to induce unilateral low back muscle pain. Automatic activity of the multifidus muscle during arm lifts was evaluated with dynamic ultrasound measurement, by assessing muscle thickness change during contraction. Multifidus activity of 15 healthy subjects was compared in a non-pain and in a pain condition, at different spinal levels (L3-L4-L5) and at both body sides. Unilateral induced pain at one segmental level reduced muscle thickness increase during contraction, at both body sides and at different lumbar levels. These results do suggest that unilateral pain may have a more widespread effect on multifidus muscle recruitment, affecting the left and right muscles, at different lumbar levels.

MRI analysis of muscle/fat index of the superficial and deep neck muscles in an asymptomatic cohort.

All muscles of the neck have a role in motion and postural control of the cervical region. The aim of this study was to investigate the difference in muscle/fat index between (1) cervical flexors and extensors and (2) deep and superficial neck muscles. Twenty-six healthy subjects participated in the study. Magnetic resonance imaging (MRI) was used to quantify muscle fat indices in different cervical flexor and extensor muscles at the C4-C5 level. Overall, the ventral muscles had a significantly lower fat content compared with the dorsal muscles (P < or = 0.001). For the cervical extensors, significant differences between the muscle/fat index of the deep and superficial muscles were found (P < or = 0.001). For the cervical flexors, there were no significant differences between the different muscles. The higher fat content in the dorsal muscles can be explained by a discrepancy in function between the spine extensors and flexors, reflected in a different muscle fiber distribution. The rather small differences between superficial and deep neck muscles are in line with recent findings that have demonstrated that both muscles groups exhibit phasic activity during isometric muscles contractions and the presumption that there is no difference in fiber type distribution between superficial and deep neck muscles.

Internal impingement in the tennis player: rehabilitation guidelines.

Internal impingement is a commonly described cause of shoulder pain in the overhead athlete, particularly in tennis players. Three shoulder dysfunctions, often correlated with internal impingement symptoms, require attention in the rehabilitation strategy of internal impingement in the tennis player: (1) acquired glenohumeral anterior instability, (2) loss of internal rotation range of motion, and (3) lack of retraction strength. Based on recent literature, the following guidelines are proposed in the rehabilitation of the tennis player with internal impingement symptoms: (1) shoulder rehabilitation should be integrated into kinetic chain training, not only in the advanced phases of the athlete's rehabilitation, but from the initial phases; (2) both angular and translational mobilisations can be used in the treatment of acquired loss of glenohumeral internal rotation range of motion to stretch the posterior structures of the glenohumeral joint; and 3) in the rehabilitation of scapular dyskinesis, the therapist should focus on restoration of intramuscular trapezius muscle balance in the scapular exercises, with special attention to strength training of the retractors.

Individual and work related risk factors for neck pain among office workers: a cross sectional study.

Work related neck disorders are common problems in office workers, especially among those who are intensive computer users. It is generally agreed that the etiology of work related neck disorders is multidimensional which is associated with, and influenced by, a complex array of individual, physical and psychosocial factors. The aim of the current study was to estimate the one-year prevalence of neck pain among office workers and to determine which physical, psychological and individual factors are associated with these prevalences. Five hundred and twelve office workers were studied. Information was collected by an online questionnaire. Self-reported neck pain during the preceding 12 months was regarded as a dependent variable, whereas different individual, work-related physical and psychosocial factors were studied as independent variables. The 12 month prevalences of neck pain in office workers was 45.5%. Multivariate analysis revealed that women had an almost two-fold risk compared with men (OR = 1.95, 95% CI 1.22-3.13). The odds ratio for age indicates that persons older than 30 years have 2.61 times more chance of having neck pain than younger individuals (OR = 2.61, 95% CI 1.32-3.47). Being physically active decreases the likelihood of having neck pain (OR = 1.85, 95% CI 1.14-2.99). Significant associations were found between neck pain and often holding the neck in a forward bent posture for a prolonged time (OR = 2.01, 95% CI 1.20-3.38), often sitting for a prolonged time (OR = 2.06, 95% CI 1.17-3.62) and often making the same movements per minute (OR = 1.63, 95% CI 1.02-2.60). Mental tiredness at the end of the workday (OR = 2.05, 95% CI 1.29-3.26) and shortage of personnel (OR = 1.71, 95% CI 1.06-2.76) are significantly associated with neck pain. The results of this study indicate that physical and psychosocial work factors, as well as individual variables, are associated with the frequency of neck pain. These association patterns suggest also opportunities for intervention strategies in order to stimulate an ergonomic work place setting and increase a positive psychosocial work environment.

Intra-operator and inter-operator reliability of surface electromyography in the clinical evaluation of back muscles.

As a prerequisite to the use of a test battery based on electromyographic (EMG) analysis of the paraspinal muscles for identifying and remedying back muscle dysfunction, the intra- and inter-operator reliability was assessed. Fifteen volunteers underwent EMG tests on three occasions. The test subjects were asked to perform 22 exercises, subdivided into four categories: coordination, stabilization, balance and strength exercises. The time interval between the tests was one week. The myoelectric signals of the multifidus (MF) and iliocostalis lumborum pars thoracis (ICLT) were analysed with regard to amplitude (averaged EMG) and frequency (zero cross rate). The results indicated that the reliability was better for the MF than for the ICLT, and also for exercises at higher loads (strength exercises). In the intra-operator condition, the reproducibility of the averaged EMG was good (ICC>0.75), except for the balance exercises (ICC = 0.40-0.74). In general, the averaged EMG in the inter-operator condition and the zero cross rate in both the intra- and inter-operator conditions are less or poorly reliable. These results demonstrate that when back muscle function is evaluated during coordination, stabilization and strength exercises, only the averaged EMG parameter has acceptable reproducibility over time when assessed by the same operator.