Long-lasting Musculoskeletal Pain Research Articles

Effects of cognitive behavioral therapy in patients with fibromyalgia: a single blind, randomized controlled study

INTRODUCTION: Fibromyalgia (FM) is a long-lasting musculoskeletal pain, which remains a problematic clinical entity globally and the management of this condition is a challenge for the health providers. Numerous individual treatment options are available to improve the symptoms of fibromyalgia, but a specificity tailored to particular patient is still missing. Thus, in this study we tested both the individual effects of physiotherapy techniques and the combination of cognitive behavioral therapy along with physiotherapy techniques would bring any changes on the fibromyalgia symptoms. OBJECTIVE: To determine the combined effect of cognitive behavioral therapy along with physiotherapy techniques in the management of fibromyalgia symptoms. METHODS: This experimental study recruited 60 FM participants aged 18-50 years from Dehradun, India and were randomized into one of 2 groups: Integrated Physiotherapy only, integrated physiotherapy and cognitive behavioral therapy for 12 weeks. Visual analogue scale, revised fibromyalgia impact questionnaire, beck depression index, shortform-36 health surveys, Pain pressure algometer, General Anxiety Disorder - 7 were recorded at baseline, four weeks, eight weeks and twelve weeks. RESULTS: After three months significant improvement (p<0.05) were noted on all the above outcome measures of integrated physical therapy and cognitive behavioral therapy group. CONCLUSION: Cognitive behavioral therapy combined with Physiotherapy treatment had an effect to reduce the depression and disability, improvement on the quality of life on fibromyalgia.

Norwegian Psychomotor Physiotherapy versus Cognitive Patient Education and active physiotherapy-A randomized controlled trial.

Norwegian Psychomotor Physiotherapy (NPMP) has been an established treatment approach for more than 50 years, mostly in the Scandinavian countries, usually applied to patients with widespread and long-lasting musculoskeletal pain and/or psychosomatic disorders. Few studies have investigated the outcomes of NPMP, and no randomized clinical trials (RCT) with a comparing treatment group have systematically been tried out on individuals. This is a pragmatic, single-blinded RCT where 128 participants with long-lasting widespread musculoskeletal pain and/or pain located to the neck and shoulders were block randomized to NPMP or Cognitive Patient Education combined with active individualized physiotherapy (COPE-PT). Intention-to-treat with linear mixed models were used to estimate the group differences in treatment effects. The outcomes at 3, 6, and 12 months follow-up were pain intensity, function, anxiety and depression, quality of life, sleep, fear of movement, and subjective health complaints. Risk profile (Örebro) was examined at 3 and 6 months. All participants underwent physical tests at baseline and 6 months. One-year data were available for 66.4% of the original participants. Calculated with intention-to-treat analysis, at 3 months statistically significant differences were found in favor of COPE-PT for pain, anxiety and depression, quality of life-physical dimension, risk profile and fear of movement. At 6 months, statistically significant differences in favor of COPE-PT were found for anxiety and depression, and sleep. At 12 months, the improvements were still statistically significant for anxiety, depression and sleep. Both groups improved, but no statistically significant differences were found between the groups on the physical tests at 6 months. COPE-PT, which is targeted towards pain-coping and increasing activity, contribute to more improvements than NPMP.

Transferring patients’s experiences of change from the context of physiotherapy to daily life

ABSTRACT Purpose: In the treatment of patients with long-lasting musculoskeletal pain, the challenge is to identify causal and sustaining factors and targeted treatment in order to improve function. Norwegian Psychomotor Physiotherapy (NPMP) is an approach often applied to patients with such pain. Long-term NPMP processes from the patients’ perspective have been studied and discussed in the light of phenomenology of the body. The study purpose was to explore what kind of changes patients with long-lasting musculoskeletal pain experience during NPMP and further transfer into daily life context. Methods: A phenomenological, descriptive, and retrospective design was applied. Two focus-group interviews were conducted with 11 patients receiving such treatment. The interviews were audiotaped, transcribed, and analysed inspired by Giorgi’s phenomenological methodology. Results: The analysis resulted in an overarching structure: “To develop embodied ownership of oneself over time”, and two themes describing the essence of change that the patients experienced: (1) “To get an embodied grip on oneself through treatment”; (2) “To give oneself space in daily life”. Conclusions: Enhanced embodied self-perception involving a sense of embodied ownership and agency seemed to be important both to be aware of own bodily needs and to transfer changes from treatment into daily life.

Cerebral peak alpha frequency reflects average pain severity in a human model of sustained, musculoskeletal pain.

Heightened pain sensitivity, the amount of pain experienced in response to a noxious event, is a known risk factor for development of chronic pain. We have previously reported that pain-free, sensorimotor peak alpha frequency (PAF) is a reliable biomarker of pain sensitivity for thermal, prolonged pains lasting tens of minutes. To test whether PAF can provide information about pain sensitivity occurring over clinically relevant timescales (i.e., weeks), EEG was recorded before and while participants experienced a long-lasting pain model, repeated intramuscular injection of nerve growth factor (NGF), that produces progressively developing muscle pain for up to 21 days. We demonstrate that pain-free, sensorimotor PAF is negatively correlated with NGF pain sensitivity; increasingly slower PAF is associated with increasingly greater pain sensitivity. Furthermore, PAF remained stable following NGF injection, indicating that the presence of NGF pain for multiple weeks is not sufficient to induce the PAF slowing reported in chronic pain. In total, our results demonstrate that slower pain-free, sensorimotor PAF is associated with heightened sensitivity to a long-lasting musculoskeletal pain and also suggest that the apparent slowing of PAF in chronic pain may reflect predisease pain sensitivity.NEW & NOTEWORTHY Pain sensitivity, the intensity of pain experienced after injury, has been identified as an important risk factor in the development of chronic pain. Biomarkers of pain sensitivity have the potential to ease chronic pain burdens by preventing disease emergence. In the current study, we demonstrate that the speed of pain-free, sensorimotor peak alpha frequency recorded during resting-state EEG predicts pain sensitivity to a clinically-relevant, human model of prolonged pain that persists for weeks.

The Revised Body Awareness Rating Questionnaire: Development Into a Unidimensional Scale Using Rasch Analysis.

The Body Awareness Rating Questionnaire (BARQ) is a self-report questionnaire aimed at capturing how people with long-lasting musculoskeletal pain reflect on their own body awareness. Methods based on classical test theory were applied to the development of the instrument and resulted in 4 subscales. However, the scales were not correlated, and construct validity might be questioned. The primary purpose of this study was to explore the possibility of developing a unidimensional scale from items initially collected for the BARQ using Rasch analysis. A secondary purpose was to investigate the test-retest reliability of a revised version of the BARQ. This was a methodological study. Rasch and reliability analyses were performed for 3 samples of participants with long-lasting musculoskeletal pain. The first Rasch analysis was carried out on 66 items generated for the original BARQ and scored by 300 participants. The items supported by the first analysis were scored by a new group of 127 participants and analyzed in a second Rasch analysis. For the test-retest reliability analysis, 48 participants scored the revised BARQ items twice within 1 week. The 2-step Rasch analysis resulted in a unidimensional 12-item revised version of the BARQ with a 4-point response scale (scores from 0 to 36). It showed a good fit to the Rasch model, with acceptable internal consistency, satisfactory fit residuals, and no disordered thresholds. Test-retest reliability was high, with an intraclass correlation coefficient of .83 (95% CI = .71-.89) and a smallest detectable change of 6.3 points. The small sample size in the second Rasch analysis was a study limitation. The revised BARQ is a unidimensional and feasible measurement of body awareness, recommended for use in the context of body-mind physical therapy approaches for musculoskeletal conditions.

Vocational rehabilitation: An educational review

The aim of this review is to describe aspects of vocational rehabilitation relevant for a physician aiming to become a specialist in physical and rehabilitation medicine (PRM). The review discusses the epidemiology of incapacity for work, the major patient groups in vocational rehabilitation (musculoskeletal and psychiatric diagnoses comprise approximately 50-70% of the patients), the influence of different kinds of environmental and individual risk factors on work resumption (such as the legal framework, application of the law, resources for rehabilitation and its effectiveness, the degree of co-operation between vocational rehabilitation agencies, economic factors/labour market situation, medical and personal factors). The review describes different models of vocational rehabilitation, the effectiveness of various vocational rehabilitation programmes on work resumption or sick leave (where strong evidence is reported for multi-modal rehabilitation programmes for patients with long-lasting musculoskeletal pain). Finally, there are sections about the PRM physician's history-taking in vocational rehabilitation (using the International Classification of Functioning, Disability and Health (ICF)), and report writing with a structure where ICF body functions and activity limitations are reported separately.

Sensitivity to Change and Responsiveness of the Global Physiotherapy Examination (GPE-52) in Patients With Long-Lasting Musculoskeletal Pain

The sensitivity to change and the responsiveness of the Global Physiotherapy Examination (GPE-52) were examined in patients with localized and widespread long-lasting musculoskeletal pain. All included patients were on sick leave and constituted the treatment group in a randomized controlled study. Two hundred forty-seven patients (64% women; mean age = 43.6 years, SD = 10.4) were included. At entry, the patients were categorized into 3 groups according to pain localization. Patients who returned fully to work were compared with those who did not. The GPE-52 has composite scores in 5 main domains--posture (8 tests), respiration (8 tests), movement (16 tests), muscle (12 tests), and skin (8 tests)--and was administered before and after 4 weeks of multidisciplinary outpatient treatment and at a 6-month follow-up examination. The first 61 patients also were re-examined after 18 months. In this study, the GPE-52 and its 5 main domains were demonstrated to be sensitive to change, measured 6 and 18 months after treatment, in different groups of patients with long-lasting musculoskeletal pain. Responsiveness to important change, defined in this study as return to work, was found only for the total GPE-52 score and within the movement and respiration domains. Responsiveness to important change was greater in patients with localized pain than in patients with widespread pain. Although the total GPE-52 score was sensitive to change in patients with long-lasting musculoskeletal pain, a shorter test battery including only the respiration and movement domain scores might be appropriate as an outcome measure in intervention studies for patients with long-lasting musculoskeletal pain.

Examination of movement in patients with long-lasting musculoskeletal pain: reliability and validity.

An examination method based on psychosomatic physiotherapy, with 24 standardized tests related to general aspects of mobility, flexibility and the ability to relax, is used in some pain and rehabilitation clinics in Scandinavia in order to document where--and to what degree--patients have aberrations within the domain 'movement'. The measurement properties of the movement tests have, however, not been investigated in patients with long-lasting musculoskeletal pain. The aims of the present study were, therefore, to investigate inter-tester reliability and validity (construct, discriminative and concurrent validity) related to movement. The study design was cross-sectional. Reliability was examined by three physiotherapists examining 19 people. Construct validity was studied by means of structural equation modelling (SEM). Discriminative validity was examined by comparing movement data from 247 patients with long-lasting musculoskeletal pain, and 104 healthy subjects. The patient sample was categorized according to localized or widespread pain, and movement scores compared between the groups. Most patients filled in a psychological screening questionnaire (MMPI-2), plus information about pain intensity and function, and concurrent validity of the movement measures were examined by correlation. SEM results indicated a modified movement scale, consisting of 16 items in four subscales. Both the original and modified versions showed good reliability, and scores differed significantly between healthy subjects and patients, and between patients with localized versus widespread pain. A relationship was found between the movement tests and psychological characteristics, but mainly in patients with widespread pain. Significant relationships were found between the ability to relax and pain, and between all aspects of movement and function. Movement may be reliably and validly assessed with composite scores from 4 x 4 items. The method may be useful as a global screening instrument in order to examine where, and to what extent, patients with long-lasting pain problems have movement aberrations; findings to be addressed in treatment.

Discriminative Validity of the Global Physiotherapy Examination-52 in Patients with Long-Lasting Musculoskeletal Pain versus Healthy Persons

Objectives: The aims of this study were to evaluate the discriminative ability of a body examination in healthy subjects versus patients with long-lasting musculoskeletal pain, and further to compare physical findings in patients with localized versus widespread pain, and between women and men.Methods: The Global Physiotherapy Examination [GPE-52] was used to evaluate bodily aberrations in 247 patients [159 women, 88 men] with long-lasting musculoskeletal pain. The GPE consists of 52 standardized tests within five main domains: Posture, Respiration, Movement, Muscle, and Skin. Patients were categorized into three subgroups according to pain distribution: pain localized either to the upper or lower body, or widespread pain. For comparison, 104 healthy persons without pain [64 women, 40 men] were also examined.Results: Significant differences were found between healthy persons and patients within all five main domains, most within the Movement and Muscle domains, least within the Respiration and Skin domain...

Palpation of Muscle and Skin. Is this a Reliable and Valid Procedure in Assessment of Patients with Long-lasting Musculoskeletal Pain?

The aims of this study were to investigate reliability and aspects of validity of a previously developed method called the Global Physiotherapeutic Muscle Examination (GPM), which comprises items related to palpation of Muscle (18 items) and Skin (12 items). Inter-tester reliability was examined by three physiotherapists examining 19 persons. Construct and discriminative validity was studied by data from 247 patients with long-lasting musculoskeletal pain and 104 healthy subjects. For the patients, concurrent validity was examined by correlating psychological functioning, measured with the revised version of the Minnesota Multiphasic Personality Inventory (MMPI-2), as well as information about pain, with the domains of Muscle and Skin. Reliability was acceptable, with overall intra-class correlation coefficients ranging from 0.54 to 0.84, but with low measurement error. Construct evaluation was done by means of Structural Equation Modeling (SEM), resulting in a modified and improved model with fewer tests...

Palpation of Muscle and Skin. Is this a Reliable and Valid Procedure in Assessment of Patients with Long-lasting Musculoskeletal Pain?

Palpation of Muscle and Skin. Is this a Reliable and Valid Procedure in Assessment of Patients with Long-lasting Musculoskeletal Pain?

Back Performance Scale for the Assessment of Mobility-Related Activities in People With Back Pain

Activities that require mobility of the trunk are often limited in patients with back problems. For this study, 5 tests (Sock Test, Pick-up Test, Roll-up Test, Fingertip-to-Floor Test, and Lift Test), all requiring sagittal-plane mobility, were performed, and the test scores were combined by the authors in a scale called the Back Performance Scale (BPS) to obtain a performance measure of mobility-related activities. The participants were 288 patients with long-lasting musculoskeletal pain. The basis for constructing a sum scale (BPS), discriminative ability, and responsiveness to important change of the BPS were examined in patients with back pain. Bivariate correlations (rs) of scores among tests ranged from.27 to.50, and correlations between separate tests and the BPS ranged from.63 to.73. The Cronbach alpha was.73. The BPS sum scores discriminated between patients with different return to work status and were higher for back pain than for other musculoskeletal pain. Responsiveness was high (effect size=1.33) in patients who had changed and low (effect size=0.31) in patients who had not changed, using return to work as an external indicator of important change. The BPS was more responsive than the separate tests. The BPS appears to measure an aspect of physical performance that is of clinical importance to patients with back pain.

Examination of Respiration in Patients with Long-lasting Musculoskeletal Pain: Reliability and Validity

Clinical examination of respiration may be an important aspect of musculoskeletal problems, but has scarcely been reported. The aims of this study were to evaluate the reliability and validity of the domain Respiration, containing 12 items oriented towards the inspection of respiratory movement and rhythm. Inter-tester reliability was examined by three physiotherapists examining 19 persons. Construct and discriminative validity of the Respiration method was studied by data from 247 patients with long-lasting muscu loskeletal pain and 104 healthy subjects. Concurrent validity to psychological variables and pain was also examined. Responsiveness was studied by comparing change in Respiration in patients who returned fully to work vs. those still on sick leave 6 months after rehabilitation. The results indicated fair but acceptable reliability. A modified Respiration scale consisting of eight items was obtained by means of Structural Equation Modeling (SEM). Respiration scores differed significantly between healthy subjects and patients. A relationship was found between Respiration and psychological characterisin tics, and between Respiration and pain, particularly in patients with widespread pain. Responsiveness of the Respiration method to clinically important change was demonstrated. Respiration can be reliably and validly assessed, and the method seems useful in the evaluation of patients with musculoskeletal problems and used as an outcome measure in rehabilitation.

Is there a right treatment for a particular patient group? Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain

In general, randomized controlled studies concerning return to work have failed to demonstrate significant treatment effects for long-lasting musculoskeletal pain, and most treatments examined have not been economically beneficial. Individuals ( n=654) sick-listed for at least 8 weeks with musculoskeletal pain, selected from the Norwegian mandatory sickness insurance system and volunteering to participate, were categorized into three groups differing in a prognosis score (good, medium, poor) for return to work, based on a brief, standardized screening of psychological and physiotherapy findings. They were then randomly assigned to three outpatient treatments with three different levels of intensity (ordinary treatment, light multidisciplinary, and extensive multidisciplinary treatment). The evaluation was based on 14 months follow-up data on return to work collected from social security records. The patients with good prognosis for return to work do equally well with ordinary treatment as with the two more intensive treatments. The patients with medium prognosis benefit equally from the two multidisciplinary treatments. The patients with poor prognosis receiving extensive multidisciplinary treatment returned to work at a higher rate than patients with poor prognosis receiving ordinary treatment, 55 vs. 37% ( P<0.05) at 14 months. Multidisciplinary treatment is effective concerning return to work, when given to patients who are most likely to benefit from that treatment. Measures of pain or quality of life are not included in this study. The cost–benefit analysis of the economic returns of the light multidisciplinary and the extensive multidisciplinary treatment programs yields a positive net present social value of the treatment. A simple, standardized, screening instrument including only psychological and physiotherapeutic observations may be a useful clinical tool for allocating patients with musculoskeletal pain to the right level of treatment.

Relationships between physical findings (GPE-78) and psychological profiles (MMPI-2) in patients with long-lasting musculoskeletal pain

The purpose of the study was to evaluate possible relationships between physical findings, as measured with the Global Physiotherapeutic Examination (GPE-78), and psychological characteristics, as measured with the revised Minnesota Multiphasic Personality Inventory (MMPI-2), in three groups of patients with long-lasting musculoskeletal pain. A total of 177 patients (114 women, 63 men), sick-listed owing to long-lasting musculoskeletal pain, were studied. The sample was subcategorized on the basis of pain localization, as marked on a pain drawing: group 1 = pain above a horizontal line in the thoracic-lumbar region (n = 24); group 2=pain below the line (n =48); group 3= pain both above and below the line (n =105). The GPE-78 consists of 78 standardized tests yielding quantitative information within five bodily domains: Posture, Movement, Muscle, Skin, and Respiration. Significant correlations were obtained between the GPE-78 and the MMPI-2 with regard to somatization, somatic concern, and depression. Patients with localized pain (groups 1 and 2) had few correlations between bodily findings and psychological problems compared with many inpatients with generalized pain (group 3). Women showed correlations between the domains Posture, Movement, and Muscle and psychological problems, whereas men showed correlations with Movement, Skin and Respiration. A psychosomatic MMPI-2 "V-profile" was present in groups 1 and 3. Women showed significantly higher scores than men. The relationships found between GPE-78 and MMPI-2 measures were significant, but findings differed depending on pain localization and sex. Patients with generalized pain had significantly more physical and psychological aberrations than patients with more localized pain.