Orthopaedic Manual Physical Therapy: A Modern Definition and Description.

Currently, orthopaedic manual physical therapy (OMPT) lacks a description of practice that reflects contemporary thinking and embraces advances across the scientific, clinical, and educational arms of the profession. The absence of a clear definition of OMPT reduces understanding of the approach across health care professions and potentially limits OMPT from inclusion in scientific reviews and clinical practice guidelines. For example, it is often incorrectly classified as passive care or incorrectly contrasted with exercise-therapy approaches. This perspective aims to provide clinicians, researchers, and stakeholders a modern definition of OMPT that improves the understanding of this approach both inside and outside the physical therapist profession. The authors also aim to outline the unique and essential aspects of advanced OMPT training with the corresponding examination and treatment competencies. This definition of practice and illustration of its defining characteristics is necessary to improve the understanding of this approach and to help classify it correctly for study in the scientific literature. This perspective provides a current definition and conceptual model of OMPT, defining the distinguishing characteristics and key elements of this systematic and active patient-centered approach to improve understanding and help classify it correctly for study in the scientific literature.

An international consensus on gaps in mechanisms of forced-based manipulation research: findings from a nominal group technique.

Force-Based Manipulation (FBM) including light touch, pressure, massage, mobilization, thrust manipulation, and needling techniques are utilized across several disciplines to provide clinical analgesia. These commonly used techniques demonstrate the ability to improve pain-related outcomes; however, mechanisms behind why analgesia occurs with these hands-on interventions has been understudied. Neurological, neuroimmune, biomechanical, neurovascular, neurotransmitter, and contextual factor interactions have been proposed to influence response; however, the specific relationships to clinical pain outcomes has not been well established. The purpose of this study was to identify gaps present within mechanism-based research as it relates to FBM. An international multidisciplinary nominal group technique (NGT) was performed and identified 37 proposed gaps across eight domains. Twenty-three of these gaps met consensus across domains supporting the complex multisystem mechanistic response to FBM. The strength of support for gaps within the biomechanical domain had less overall support than the others. Gaps assessing the influence of contextual factors had strong support as did those associating mechanisms with clinical outcomes (translational studies). The importance of literature investigating how FBM differs with individuals of different pain phenotypes (pain mechanism phenotypes and clinical phenotypes) was also presented aligning with other analgesic techniques trending toward patient-specific pain management (precision medicine) through the use of pain phenotyping.

Perceptions of Physical Therapy and The Role of Physical Therapists  In Injury Prevention Among Professional Basketball Players: A Qualitative Study.

Background: Injury prevention is critical in competitive professional sports, however, the role of physical therapists in this aspect of healthcare is not fully understood. Purpose: The purpose of this study was to describe professional basketball players' perceptions of physical therapy (PT) and physical therapists' role in injury prevention. Study Design: Qualitative, semi-structured interview. Methods: Thirty-five professional basketball players (mean age 23.1 years ± 3.9; 42% female; 72% African American; 90% college graduates) from over 20 teams participated. Athletes participated in semi-structured interviews that focused on injury prevention and utilization of PT services. Two researchers coded the transcripts, organized the findings into general categories, and created major themes. Data saturation was reached when no new information emerged. Results: Over half (62.9%) stated that PT mainly addressed post-injury and return-to-sport rehabilitation. An overwhelming majority of players highlighted the use of an athletic trainer (AT) over physical therapists in injury prevention due to perceived expertise and trust. Conclusion: While PTs are educated in preventive care and acute injury management, professional basketball players viewed their role primarily for return-to-sport rehabilitation. The organizational structure of healthcare in professional basketball may promote closer professional relationships with ATs while limiting those with physical therapists. The result is that elite athletes may miss out on treatment specific to the PT profession. Level of Evidence: Level 4.

Physical therapist perceptions and use of clinical pain mechanism assessment in the musculoskeletal setting: a survey analysis.

BACKGROUND: A mechanism-based approach to the evaluation and management of pain has been suggested across disciplines in contemporary research. However, the translation of pain mechanism assessment strategies in research to clinical practice is unclear. This study sought to explore perceptions and use of clinical pain mechanism assessment by physical therapists managing musculoskeletal pain. METHODS: This was an electronic cross-sectional survey. After initial development, refinement, and piloting for comprehensiveness, comprehensibility and relevance, the survey was disseminated to members of the Academy of Orthopaedic Physical Therapy via email listserv. Data was maintained anonymously using the online database REDCap. Descriptive statistics and Spearman's correlations for non-parametric data were analyzed for frequencies and associations across variables. RESULTS: In total, 148 respondents completed all aspects of the survey. Respondent age ranged from 26 to 73 years, with a mean (SD) of 43.9 (12.0). Most respondents (70.8%) reported performing clinical pain mechanism assessments at least 'sometimes'. A majority (80.4%) believed clinical pain mechanism assessments are useful in guiding management strategies while 79.8% reported specifically choosing interventions to alter aberrant pain mechanisms. The most commonly used pain severity, physical examination testing and questionnaires were the numeric pain rating scale, pressure pain thresholds and pain diagrams, respectively. However, the vast majority of instruments to clinically assess pain mechanisms were performed by a small proportion of respondents (< 30%). There were no significant correlations between age, years of experience, highest earned degree, completion of advanced training or specialist certification and testing frequency. CONCLUSION: The evaluation of pain mechanisms involved in the pain experience is becoming common in research. The clinical application of pain mechanism assessment is unclear. Based on the results of this survey, physical therapists in the orthopedic setting believe pain mechanism assessment is useful, but data suggests it is infrequently performed. Additional research to uncover clinician motivation related to pain mechanism assessment is warranted.

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.

Total ankle arthroplasty: Strength, pain, and motion.

BACKGROUND: While outcomes such as pain and ankle motion are well researched, information regarding the effect of total ankle arthroplasty on ankle plantarflexion strength is extraordinarily limited. The purpose of this study was to evaluate ankle plantarflexion strength before and after total ankle arthroplasty, and examine the interplay of pain, motion, and strength. METHODS: This prospective case-control study included 19 patients with end-stage ankle arthritis who received a total ankle arthroplasty and 19 healthy control participants matched for age, sex, and body mass index. Pain was measured with a numeric pain rating scale. Passive sagittal plane ankle range of motion (°) and isokinetic ankle plantarflexion torque (Nm/kg) at 60 and 120°/s were measured with an instrumented dynamometer. t-tests or non-parametric tests were used to evaluate outcomes across time and between groups. Bivariate correlations were performed to evaluate the interplay of postoperative pain, motion, and torque. FINDINGS: Patient pain and motion improved between the preoperative and six-month postoperative time points (d ≥ 0.7). Ankle plantarflexion torque was not different across time (d ≤ 0.5), but was lower than control group values postoperatively (d ≥ 1.4). Significant correlations between pain and motion (r = -0.48), but not torque (-0.11 ≤ r ≤ 0.13), were observed. INTERPRETATION: Unchanged following surgery, impairments in muscle performance following total ankle arthroplasty do not appear to be changed by improved pain or motion. These findings provide impetus for postoperative strengthening interventions.

Revisiting the Provision of Pain Neuroscience Education: An Adjunct Intervention for Patients but a Primary Focus of Clinician Education.

SYNOPSIS: Society is mired in a serious health care crisis regarding pain and opioid abuse. Pain neuroscience education (PNE) has gained support in the last 20 years as an intervention to help people manage chronic pain. In this Viewpoint, we argue that exercise and movement must be the primary intervention for chronic pain conditions, and that PNE or other adjunctive therapies should only be used if they can foster increased exercise and movement participation. Pain education should be the primary focus of a chronic pain management strategy for students and clinicians. It would help to advance knowledge and skills, and ultimately enhance care and outcomes for patients with chronic pain. J Orthop Sports Phys Ther 2021;51(2):57-59. doi:10.2519/jospt.2021.9804.

Hand-held dynamometer to measure pressure pain thresholds: A double-blinded reliability and validity study.

BACKGROUND: Pain is the most common complaint reported in the musculoskeletal setting. Quantitative sensory testing (QST) assists with pain mechanism identification, although QST is typically performed in research settings. It is possible that clinical utilization of QST may improve if clinically accessible tools can be reliably and validly used. OBJECTIVE: To determine if a hand-held dynamometer (HHD) can be a valid and reliable assessment of pressure pain threshold (PPT). DESIGN: Double-blinded validation study. METHODS: Eighteen healthy subjects (25.6 ± 3.4 years old) participated in this study. Two testers independently assessed PPT using a HHD and a digital algometer. Assessments followed previously described pressure algometry protocols. Testers and subjects were each blinded to data during assessments. RESULTS: Intra- and inter-rater reliability were excellent for the foot and face for both devices (ICC's > 0.9). Bland-Altman plots and intraclass correlation coefficients revealed good-excellent agreement with minimal proportional bias when normalizing device force at pain threshold to the circumference of the device applicator (ICC 95%CI: 0.56-0.95). Only poor-good agreement (ICC 95% CI: 0.30-0.76) and significant proportional bias was observed when normalizing to area (pressure). CONCLUSIONS: Based on the results of this study, when force is normalized by circumference of the applicator, a HHD was found to be a valid and reliable tool for measuring PPT. Clinicians may use HHD to detect relevant pain mechanisms at fault in their evaluation and treatment of pain. Additional research in various pathologic populations is warranted.

Effects of iliotibial band syndrome on pain sensitivity and gait kinematics in female runners: A preliminary study.

BACKGROUND: Runners with iliotibial band syndrome display symptoms similar to chronic tendinopathy and distinct gait patterns compared to healthy controls. Although altered pain processing has been demonstrated in chronic tendinopathies, central pain processing and its relationship to motor control has not been measured in iliotibial band syndrome. The purpose of this study was to examine pain sensitivity, hip strength, and gait kinematics in runners with and without iliotibial band syndrome. METHODS: Nine female runners with iliotibial band syndrome and eight healthy controls participated. Subjective pain was reported and pressure pain threshold measured at the bilateral foot, tibialis anterior, contralateral hand. Isometric hip strength was assessed. Three-dimensional joint angles were collected while running. Differences in pain and strength were determined using 1-way ANOVAs. Discrete hip and knee joint angles during stance phase were calculated and waveform analysis performed. FINDINGS: Runners with iliotibial band syndrome exhibited bilaterally diminished pain at the foot (injured-limb: 1.54 (SD = 0.51); non-injured limb: 1.54 (SD = 0.55); control: 4.01 (SD = 2.30) kg, P < .001) and ipsilateral tibialis anterior (injured-limb: 2.33 (SD = 1.10); control: 6.13 (SD = 4.89) kg, P = .03). Hip strength was not different between groups. Runners with iliotibial band syndrome had greater hip adduction at touchdown, knee internal rotation during loading, and knee abduction and flexion at toe-off than controls. INTERPRETATION: Runners with iliotibial band syndrome demonstrated expanded somatic pain sensitivity without hip strength differences, but concomitant with altered gait patterns. Bilateral pain symptoms and gait deviations exist in runners with iliotibial band syndrome even with unilateral symptoms, highlighting the importance of bilateral assessment.

BILATERAL SENSORY DEFICITS AND WIDESPREAD HYPERALGESIA OCCUR FOLLOWING INDUCED DELAYED ONSET MUSCLE SORENESS OF THE QUADRICEPS.

BACKGROUND: Unaccustomed eccentric exercise during sport or training may lead to delayed onset muscle soreness (DOMS), which has been demonstrated to influence postural control, potentially resulting in further injury. Afferent sensory input is critical to effective postural control, but little is known about somatosensory changes at the knee following induction of DOMS of the quadriceps muscle. The 'soreness' or hyperalgesia associated with DOMS has been postulated to occur because of damage to/inflammation of the exercised muscle, however, effects on central nociceptive mechanisms, which are known to induce altered postural responses, have been less studied. PURPOSE/HYPOTHESIS: It was hypothesized that DOMS of the quadriceps muscle would result in widespread hyperalgesia and hypoesthesia at the knee. Therefore, the purpose of this study was to investigate the effects of DOMS on knee somatosensory changes in asymptomatic healthy participants. STUDY DESIGN: Quasi-experimental cohort study. METHODS: Thirty participants (15 males and 15 females) took part in the study. Eccentric exercise consisted of 10 sets of 10 maximum eccentric quadriceps contractions performed with the dominant knee. Outcome measures consisted of pain intensity (Visual Analog Scale), pressure pain threshold (PPT), vibration perception threshold (VPT) and proprioception, measured via threshold to detection of passive motion (TDPM) at the knee, at three different assessment time points: (1) pre-eccentric exercise; (2) immediately and (3) 48 hours post-eccentric exercise. RESULTS: Not surprisingly, pain intensity increased and PPT of the vastus medialis and rectus femoris muscles decreased (hyperalgesia) immediately post-exercise on the exercised limb. However, at 48 hours, hyperalgesia was demonstrated at other lower extremity muscles, including bilaterally at the tibialis anterior muscles, and also at the hand. Evidence of hypoesthesia was also demonstrated. VPT and TDPM increased (worsened) ipsilaterally both immediately and 48 hours after exercise, and TDPM increased bilaterally at 48 hours. Females demonstrated greater impairment in TDPM than males at 48 hours. Expanding distribution of hyperalgesia, ipsilaterally impaired VPT and bilaterally impaired proprioception were demonstrated in the presence of DOMS. DISCUSSION/CONCLUSION: Inflammation from unaccustomed eccentric exercise may induce neuroplastic changes in nociceptive pathways resulting in wider distribution of pain and hypoesthesia. Futures studies examining the effect of DOMS related somatosensory changes on postural control may be warranted. LEVEL OF EVIDENCE: 3.

Use of thrust joint manipulation by student physical therapists in the United States during clinical education experiences.

Introduction: Thrust joint manipulation (TJM) is used in physical therapy practice and taught in entry-level curricula in the United States (US); however, research regarding implementation by student physical therapists (SPT)s is scarce. Objectives: To explore the use of TJM in SPT clinical education and factors influencing implementation. Methods: In a cross-sectional exploratory study, accredited physical therapy (PT) programs in the US (n = 227) were invited to participate in an electronic survey. SPTs were queried about TJM use and their clinical instructor's (CI) credentials during their final musculoskeletal clinical experience. Results: Forty-five programs participated in the study, consisting of 2,147 SPTs. Of those, 414 (19.3%) responses were used for analysis and 69% reported using TJM. SPTs who utilized TJM were more likely to have a CI who used TJM (p < 0.001) and/or had advanced certification/training in manual therapy (p < .001). A majority of students agreed or strongly agreed that their academic preparation provided them with clinical reasoning tools (84%) and psychomotor skills (69%) necessary to perform TJM. SPT use of TJM was facilitated by CI clinical practice, SPT competence in psychomotor skill, confidence in clinical reasoning, and practice setting. A main barrier to student use of TJM was CI lack of TJM use. Conclusions: Clinical practice of the CI appears to be a key factor in determining student use of TJM. Level of evidence: 2b.

Passive accessory joint mobilization in the multimodal management of chronic dysesthesia following thalamic stroke.

Study design: Case Report. Purpose: Stroke is the most common cause of long-term disability. Dysesthesia, an unpleasant sensory disturbance, is common following thalamic stroke and evidence-based interventions for this impairment are limited. The purpose of this case report was to describe a decrease in dysesthesia following manual therapy intervention in a patient with history of right lacunar thalamic stroke. Case description: A 66-year-old female presented with tingling and dysesthesia in left hemisensory distribution including left trunk and upper/lower extremities, limiting function. Decreased left shoulder active range of motion, positive sensory symptoms but no sensory loss in light touch was found. She denied pain and moderate shoulder muscular weakness was demonstrated. Laterality testing revealed right/left limb discrimination deficits and neglect-like symptoms were reported. Passive accessory joint motion assessment of glenohumeral and thoracic spine revealed hypomobility and provoked dysesthesia. Interventions included passive oscillatory joint mobilization of glenohumeral joint, thoracic spine, ribs and shoulder strengthening. Results: After six sessions, shoulder function, active range of motion, strength improved and dysesthesia decreased. Global Rating of Change Scale was +5 and QuickDASH score decreased from 45% to 22% disability. Laterality testing was unchanged. Conclusion: Manual therapy may be a beneficial intervention in management of thalamic stroke-related dysesthesia. Implications for Rehabilitation While pain is common following thalamic stroke, patients may present with chronic paresthesia or dysesthesia, often in a hemisensory distribution. Passive movement may promote inhibition of hyperexcitable cortical pathways, which may diminish aberrant sensations. Passive oscillatory manual therapy may be an effective way to treat sensory disturbances such as paresthesias or dysesthesia.

Hypoesthesia after anterior cruciate ligament reconstruction: The relationship between proprioception and vibration perception deficits in individuals greater than one year post-surgery.

BACKGROUND: While surgical reconstruction restores mechanical stability following anterior cruciate ligament (ACL) rupture, many experience early-onset osteoarthritis despite surgery. Neurophysiological changes are hypothesized to contribute to knee osteoarthritis progression. Proprioceptive deficits have been reported following ACL injury/reconstruction; however, vibration perception threshold (VPT) has been less studied. This study explored relationships between pain, VPT, proprioception, function, and strength following ACL-reconstruction. METHODS: Twenty individuals (27 ±â€¯6 years; 10 males) (standard deviation) status-post ACL-reconstruction were compared with a control group. Measurements included VPT, proprioception (threshold to detect passive movement), pain, function (Knee Outcome Survey (KOS)) and isometric quadriceps strength. Group differences were assessed using Mann-Whitney U tests, side-to-side differences with Wilcoxon Signed Rank tests, and associations evaluated using Spearman correlations. RESULTS: The ACL-reconstruction group had minor functional deficits (15 ±â€¯11%) and resting pain (1.8 ±â€¯1.7). Impaired VPT and proprioception (hypoesthesia) were demonstrated on surgical compared to contralateral and control limbs (p ≤ 0.008). Proprioception was significantly different between contralateral and control knees, but not VPT. Surgical knee proprioceptive deficits and VPT deficits were positively correlated (ρ = 0.462, p = 0.047) but not in controls (ρ = -0.042, p = 0.862). Strength was negatively correlated to pain (ρ = -0.589; p = 0.006), but not to KOS scores, proprioception or VPT (p ≥ 0.099). CONCLUSION: Proprioceptive deficits following ACL injury have been ascribed to loss of afferent input from the torn ligament. Alternatively, multi-modality as well as contralateral sensory deficits suggest a spinal/supraspinal source of neurophysiological findings which may predispose to early osteoarthritis. LEVEL OF EVIDENCE: III.

Duration of symptoms is associated with conditioned pain modulation and somatosensory measures in knee osteoarthritis.

Impaired descending pain inhibition has been linked to chronic pain and poorer patient outcomes. Vibration perception threshold (VPT) has also been observed and linked to radiographic stage of OA. However, it is not known how duration of symptoms may influence these neurophysiological measures. Our purpose was to evaluate the relationship between duration of symptoms and conditioned pain modulation (CPM), a measure of descending pain inhibition, and VPT, and to determine whether these relationships differed in men and women seeking orthopedic care. We evaluated 18 men and 27 women with moderate to severe knee OA. We assessed CPM using a submaximal-effort tourniquet test: Pressure pain threshold (PPT) at the symptomatic knee was evaluated before and after a noxious stimulus. CPM impairment was indicated by a ratio of pre-to-post stimulus PPT ≥1. VPT was assessed using a biothesiometer at the medial femoral condyle. We used chi-square, t-tests and Pearson correlations to address study questions. 72% of men, but only 44% of women had CPM impairment. Duration of symptoms was associated with CPM impairment in women (R = 0.566, p = 0.003) but not men (R = 0.366, p = 0.135). Duration of symptoms was also associated with VPT in both men (R = 0.580, p = 0.012) and women (R = 0.406, p = 0.039). These results suggest that longer duration of knee OA may predict more severe pain sensitization and that important sex differences exist in descending pain inhibition in people with chronic knee OA that may affect disease and course of treatment in male and female patients. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.

The status of temporomandibular and cervical spine education in post-professional physical therapy training programs recognized by Member Organizations of IFOMPT: an investigation of didactic and clinical education.

OBJECTIVES: The purpose of this investigation was to establish an international baseline of the quantity of physical therapist education on temporomandibular disorders (TMD) during post-professional Orthopedic Manual Physical Therapy (OMPT) education. METHODS: An electronically distributed survey was sent to programs and data analyzed for trends, including a comparison of TMD and cervical spine disorders education. Current data were compared to pre-existing data from the United States. RESULTS: For the current data-set, the Mann-Whitney U test demonstrated statistical significance when comparing TMD and cervical spine disorders education for both the hours of didactic training provided (p < 0.0001) and the number of patients seen during clinical training (p < 0.006). When comparing the United States and international data, statistically significant greater exposure was reported for both didactic (p < 0.0001) and clinical education (p < 0.006) of TMD topics in the United States but not for didactic (p = 0.23) or clinical education (p = 0.15) of cervical spine topics. DISCUSSION: These data again indicate a lack of uniformity between post-professional training programs in OMPT with respect to TMD education. There is, however, consistency in that most programs provided more training on cervical spine disorders than TMD. Based on these findings, further investigations are appropriate to determine if TMD education is adequate during post-professional OMPT education.

The effects of joint mobilization on individuals with patellofemoral pain: a systematic review.

OBJECTIVE: To investigate and synthesize the effects of joint mobilization on individuals with patellofemoral pain syndrome. DATA SOURCES: Five electronic databases (CINAHL, the Cochrane Central Register of Controlled Trials, PubMed, Scopus, and SPORTDiscus) were used. REVIEW METHODS: Each database was searched from inception to 1 November 2017. Randomized controlled trials investigating a manual therapy intervention, with or without co-interventions, for persons with patellofemoral pain were included. Two reviewers independently screened the retrieved literature and appraised the quality of the selected studies using the PEDro rating scale. A third reviewer was used in cases of discrepancy to create a consensus. RESULTS: A total of 361 articles were identified in the search. Twelve randomized trials with a total of 499 participants were selected for full review. Within-group improvements in pain and function were noted for the manual therapy groups. Between-group improvements for short-term outcomes (three months or less) were greatest when joint mobilization was directed to the knee complex and used as part of a comprehensive approach. CONCLUSION: In the articles reviewed, joint mobilization appears to be most effective in improving pain and function when coupled with other interventions, although its discrete effect is unclear due to the reviewed studies' design and reporting.

Exploration of Quantitative Sensory Testing in Latent Trigger Points and Referred Pain Areas.

OBJECTIVE: The objective of this study was to investigate somatosensory nerve fiber function by applying different quantitative sensory testing including thermal, mechanical, and vibration thresholds over latent trigger points (TrP) and in its associated referred pain area. METHODS: A total of 20 patients with unilateral latent TrPs in the extensor carpi radialis brevis were included. Warmth detection threshold (WDT), cold detection threshold (CDT) and heat/cold pain thresholds (HPT, CPT), mechanical detection (MDT) and pain (MPT) thresholds, vibration threshold (VT), and pressure pain thresholds (PPT) were blinded assessed over the TrP, in the referred pain area, and in the respective contralateral mirror areas. A multilevel mixed-model ANOVA with site (TrP, referred pain area) and side (real or contralateral) as within-patient factors and sex as between-patients factor was conducted. RESULTS: No significant differences for thermal detection (WDT, CDT) or thermal pain thresholds (HPT, CPT) were found (all, Ps>0.141). The assessments over the TrP area showed lower PPT and MDT compared with the mirror contralateral TrP area (P<0.05). MDT were higher (P=0.001) but PPT (P<0.001) and MPT (P=0.032) were lower over the TrP area and contralateral mirror point compared with their respectively referred pain areas. Finally, VT was higher over the TrP area than in the referred pain area and over both mirror contralateral points. DISCUSSION: Assessing sensory changes over latent myofascial TrPs reveal mechanical hyperesthesia, pressure pain hyperalgesia, and vibration hypoesthesia compared with a contralateral mirror area.

Clinical descriptors for the recognition of central sensitization pain in patients with knee osteoarthritis.

BACKGROUND: Despite growing awareness of the contribution of central pain mechanisms to knee osteoarthritis pain in a subgroup of patients, routine evaluation of central sensitization is yet to be incorporated into clinical practice. AIM: The objective of this perspective is to design a set of clinical descriptors for the recognition of central sensitization in patients with knee osteoarthritis that can be implemented in clinical practice. METHODS: A narrative review of original research papers was conducted by nine clinicians and researchers from seven different countries to reach agreement on clinically relevant descriptors. RESULTS: It is proposed that identification of a dominance of central sensitization pain is based on descriptors derived from the subjective assessment and the physical examination. In the former, clinicians are recommended to inquire about intensity and duration of pain and its association with structural joint changes, pain distribution, behavior of knee pain, presence of neuropathic-like or centrally mediated symptoms and responsiveness to previous treatment. The latter includes assessment of response to clinical test, mechanical hyperalgesia and allodynia, thermal hyperalgesia, hypoesthesia and reduced vibration sense. CONCLUSIONS: This article describes a set of clinically relevant descriptors that might indicate the presence of central sensitization in patients with knee osteoarthritis in clinical practice. Although based on research data, the descriptors proposed in this review require experimental testing in future studies. Implications for Rehabilitation Laboratory evaluation of central sensitization for people with knee osteoarthritis is yet to be incorporated into clinical practice. A set of clinical indicators for the recognition of central sensitization in patients with knee osteoarthritis is proposed. Although based on research data, the clinical indicators proposed require further experimental testing of psychometric properties.