Musculoskeletal Pain Conditions Research Articles

Differential Sensitization of Muscle versus Fascia in Individuals with Low Back Pain.

Muscles and the deep fascia surrounding them have been suggested to play an important role in various musculoskeletal pain conditions including low back pain. Both have been shown to host rich nociceptive innervation and to undergo changes in individuals with chronic pain. However, evidence for the respective contribution of muscle and fascia sensitization in humans with myofascial pain syndrome is lacking. Here, we studied the sensitization of muscle and fascia in individuals with myofascial low back pain. Twenty individuals with acute (5) and chronic (15) myofascial low back pain of the quadratus lumborum muscle and a matched control group of twenty healthy individuals were recruited and clinically evaluated. All participants underwent ultrasound-guided needling of their subcutaneous tissue, deep fascia and quadratus lumborum muscle. Reported pain intensity and episodes of muscle twitching were recorded and analyzed. Among pain patients, both muscles and deep fascia demonstrated pain hypersensitivity, but muscles were significantly more sensitized than the deep fascia. No difference between acute- or chronic-pain patients was observed. Results of this study suggest that while both deep fascia and muscle show pain sensitization in both early and chronic stages of low back pain, muscles are more sensitized than fascia.

Differential Effects Of Exercise Induced Muscle Damage On Multiple Noxious Stimuli

Many clinical musculoskeletal pain conditions are characterized by chronic inflammation. Inflammation leads to the release of inflammatory cytokines that activate or sensitizes nociceptors leading to pain sensitivity. An unresolved issue is whether inflammation affects all nociceptors in a similar manner. Exercise induced muscle damage in the days following a bout of eccentric exercise has been proposed as a valid model of simulating clinical inflammatory pain to be used in healthy samples. PURPOSE: We sought to induce localized inflammation using eccentric exercise to test various painful stimuli (pressure, thermal, and electrical) regarding an individual’s pain sensitivity in a limb that was eccentrically exercised versus a limb that was not exercised. METHODS: 18 healthy participants (9F, age: 24.6 ± 3.3) completed baseline pressure pain thresholds (PPT), thermal pain threshold (TPT), and nociceptive flexion reflex (NFR) in both legs and again 48 hours after a muscle damaging protocol. The participants performed a minimum of 6 rounds of 10 eccentric leg extension exercises to induce muscle damage and localized inflammation in the right quadriceps only. RESULTS: Significant main effect of time for PPT (%diff; -58.9 ± 23.1; p = 0.02, ηp2 = 0.28) but no main effect was observed for limb (%diff; -15.5 ± 23.9; p = 0.53, ηp2 = 0.02). In contrast there was a significant interaction between time and limb (p < 0.001, ηp2 = 0.47) whereby post hoc correction revealed participants had lower PPT’s in the right leg only after the damage protocol (%diff; -105.9 ± 29.2; p = 0.002). No main effects or interactions were observed for TPT and NFR. CONCLUSION: Those with chronic inflammatory pain usually have an increased sensitivity to pressure, thermal, and electrical stimuli whereas our sample with acute inflammation only had sensitivity to mechanical pain. Exercise induced inflammation may reflect a peripheral sensitivity localized to the damage muscle rather than a global sensitivity that those with chronic pain display.

Potential role of blood constituents in pain-relief associated with fibromyalgia treatment with extremely low magnetic field: Spectroscopic investigation

Magnetic field is used as an adjunct therapy for pain control and relief of musculoskeletal pain conditions as Fibromyalgia. It is regarded as more natural and less harmful alternative to analgesic compounds. The exact mechanism underlying these positive effects is still to be determined. Twenty-three patients diagnosed with Fibromyalgia condition were included in this study, and subjected to extremely low magnetic field treatment sessions. The treatment protocol based on exposing patients to gradually increased magnetic field strength that starts with 0.1 μT at the beginning, and increased gradually to 100 μT (3.33 μT/min). UV–Visible, mid-IR and fluorescence characteristics of whole blood, erythrocytes and hemoglobin were investigated; in addition to RBCs-osmotic fragility measurements. The obtained results were analyzed according to control-sham exposed patients. We observed marked changes in the blood (and/or its constituents) absorption spectra of fibromyalgia patients that indicate an enhancement in the energetic pathways and increased hemoglobin-oxygen affinity; in addition, the osmotic fragility measurements show that erythrocytes were characterized by increased elasticity and rehydration. The analyses of infrared spectra show that magnetic field treatment was associated with changes in the erythrocytes skeleton where α-helix component of protein secondary structure is dominant. This study provides scientific evidence that pain relief associated with extremely low magnetic field treatment can be directly related to its systemic effects as well as the enhancement of the cellular activities.

Association of poor sleep with low back pain among symptomatic and asymptomatic population

Although Low back pain puts an immerse economic strain on healthcare services, this disease is responsible for impacting people’s daily lives. Sleep quality has gained interest for people with musculoskeletal pain conditions as a contributing factor to the outcome. Sleep consistency has created consideration as a risk factor to the outcomes for people with MSK pain disorders. According to several studies, there is a bidirectional relationship between pain severity and sleep quality. The recent focus on the interaction of inflammatory processes in pain and sleep, on the one hand, leads to neuro-immunological pathways that may contribute to the close relationship between pain and sleep, on the other. To study association of poor sleep with low back pain among symptomatic and asymptomatic population. All asymptomatic and symptomatic individuals with low back pain in the group between 35-50 years of age filled the survey using Visual Analogue Scale (VAS) and Insomnia Severity Index Questionnaire, and the data was analyzed. There's a link between low back pain and a lack of sleep. When compared to asymptomatic individuals, the visual analogue score for pain and the insomnia severity index score were higher in the symptomatic low back pain population, implying a bidirectional relationship between low back pain and poor sleep. In thisstudy, we discovered a link between poorsleep and low back discomfort. Thisresearch found that there is a bidirectional relationship between low back discomfort and poor sleep, with one affecting the other and vice versa

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Efficacy and Effectiveness of Extracorporeal Shockwave Therapy in Patients with Myofascial Pain or Fibromyalgia: A Scoping Review.

Myofascial pain syndrome (MPS) and fibromyalgia (FM) are underestimated painful musculoskeletal conditions that could impact function and quality of life. A consensus about the most appropriate therapeutic approach is still not reached. Considering the long course of the diseases, prolonged assumption of drugs, such as NSAIDs and pain killers, could increase the risk of adverse events, often leading affected patients and physicians to prefer non-pharmacological approaches. Among these, radial and focused extracorporeal shock waves therapies (ESWT) are widely used in the management of painful musculoskeletal conditions, despite the fact that the mechanisms of action in the context of pain modulation should be further clarified. We performed a scoping review on PubMed using Mesh terms for analyzing the current evidence about the efficacy and effectiveness of ESWT for patients with MPS or FM. We included 19 clinical studies (randomized controlled trials and observational studies); 12 used radial ESWT, and 7 used focused ESWT for MPS. Qualitative analysis suggests a beneficial role of ESWT for improving clinical and functional outcomes in people with MPS, whereas no evidence was found for FM. Considering this research gap, we finally suggested a therapeutic protocol for this latter condition according to the most recent diagnostic criteria.

Digital Rehabilitation for Elbow Pain Musculoskeletal Conditions: A Prospective Longitudinal Cohort Study.

Elbow musculoskeletal pain (EP) is a major cause of disability. Telerehabilitation has shown great potential in mitigating musculoskeletal pain conditions, but EP is less explored. This single-arm interventional study investigates clinical outcomes and engagement levels of a completely remote multimodal digital care program (DCP) in patients with EP. The DCP consisted of exercise, education, and cognitive-behavioral therapy for 8 weeks. Primary outcome: disability change (through the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), treatment response cut-offs: 12.0-point reduction and 30% change). Secondary outcomes: pain, analgesic intake, surgery intent, mental health, fear–avoidance beliefs, work productivity, and patient engagement. Of the 132 individuals that started the DCP, 112 (84.8%) completed the intervention. Significant improvements were observed in QuickDASH with an average reduction of 48.7% (11.9, 95% CI 9.8; 14.0), with 75.3% of participants reporting ≥30% change and 47.7% reporting ≥12.0 points. Disability change was accompanied by reductions in pain (53.1%), surgery intent (57.5%), anxiety (59.8%), depression (68.9%), fear–avoidance beliefs (34.2%), and productivity impairment (72.3%). Engagement (3.5 (SD 1.4) sessions per week) and satisfaction 8.5/10 (SD 1.6) were high. The significant improvement observed in clinical outcomes, alongside high engagement, and satisfaction suggests patient acceptance of this care delivery mode.

Disparities Exist in Physical Therapy Utilization and Time to Utilization Between Black and White Patients With Musculoskeletal Pain.

Black patients are less likely than White patients to receive physical therapy for musculoskeletal pain conditions. Current evidence, however, is limited to self-reported conditions and health services use. The purpose of this study was to use a large electronic health record database to determine whether a race disparity existed in use of physical therapy within 90days of a new musculoskeletal diagnosis. Eligible patients (n = 52,384) were sampled from an Optum deidentified electronic health record database of 5 million adults distributed throughout the United States. In this database, patients were designated as "Black" and "White." Patients were eligible if they had a new diagnosis for musculoskeletal neck, shoulder, back, or knee pain between January 1, 2012, and December 31, 2017. Logistic regression and Cox proportional hazard models were computed before and after adjusting for covariates to estimate the association between race and receipt of physical therapy services within 90days of musculoskeletal pain diagnoses. Patients were on average 47.5 (SD = 14.9) years of age, 12.8% were Black, 87.2% were White, and 52.7% were female. Ten percent of Black patients and 15.5% of White patients received physical therapy services within 90days of musculoskeletal pain diagnoses. After adjusting for covariates, White patients were 57% more likely (odds ratio = 1.57; 95% CI = 1.44-1.71) to receive physical therapy compared with Black patients and had significantly shorter time to physical therapy than Black patients (hazard ratio = 1.53; 95% CI = 1.42-1.66). In a nationally distributed cohort, Black patients were less likely than White patients to utilize physical therapy and had a longer time to utilization of physical therapy for musculoskeletal pain. These findings highlight the need to determine the mechanisms underlying the observed disparities and how these disparities influence health outcomes.

The Mediating Role of Depression and Pain Catastrophizing in the Relationship between Functional Capacity and Pain Intensity in Patients with Fibromyalgia

Background Fibromyalgia syndrome (FMS) is a chronic musculoskeletal pain condition characterized by widespread pain, sleep problems (i.e., insomnia and unrefreshing sleep), fatigue, cognitive, and emotional difficulties. Although pain has been proposed the factor mostly impacting in the FMS patients' function, emotional and psychological FMS-associated factors are also known to exert a negative impact in quality of life and functional capacity. Nonetheless, the relationship between these factors and functional limitations in FMS patients is considered to be complex and not clearly defined. Therefore, the present study is aimed at assessing the associations between FMS functional capacity, FMS symptoms (pain, fatigue, insomnia, depression, and state and trait anxiety), and associated psychological factors such as pain catastrophizing, as well as the possible mediating role of these latter in the relationship between pain and FMS functional capacity. Method 115 women diagnoses with FMS completed a set of self-administered questionnaires to evaluate the clinical and psychological variables of the study. Results FMS functional capacity was positively associated with the majority of FMS symptoms except state anxiety. Regression analyses confirmed a greater prediction for FMS functional capacity by depression, fatigue, and pain catastrophizing, in this sequence. Both, pain catastrophizing and depression were important factors mediating the association between clinical pain (total and intensity) and FMS functional capacity. Conclusions Findings support a key role of pain catastrophizing and depression in the disability associated to pain in FMS. Treatment goals directed to lessen depression and pain catastrophizing levels should be promoted to reduce the impact of pain in FMS patients' daily function.

Omics approaches to discover pathophysiological pathways contributing to human pain.

Omics approaches to discover pathophysiological pathways contributing to human pain.

High-Intensity Laser Therapy (HILT) as an Emerging Treatment for Vulvodynia and Chronic Musculoskeletal Pain Disorders: A Systematic Review of Treatment Efficacy.

High-intensity laser therapy (HILT) has been gaining popularity in the treatment of chronic musculoskeletal pain, including vulvodynia. The objective of this study was to critically appraise and synthesize the available evidence on the efficacy of HILT for reducing pain and improving function in vulvodynia and other chronic primary musculoskeletal pain conditions. Electronic databases and the grey literature were searched. Effects on pain intensity, function, and adverse events were assessed. One study investigating HILT in the treatment of vulvodynia and 13 studies on the treatment of chronic musculoskeletal pain were selected. The study assessing vulvodynia showed favorable results for reducing pain. Regarding chronic musculoskeletal pain, 12 out of the 13 studies selected consistently showed that HILT was more effective than the placebo/active comparator for reducing pain and improving function. The available effect sizes for pain showed large to huge effects. Similar effects were observed for function except for two studies showing moderate effects. The GRADE score was moderate. Conclusions: There are insufficient data to support the use of HILT in vulvodynia, but the promising results encourage further research. HILT appears to be effective in musculoskeletal pain conditions. More high-quality studies are needed to identify effective laser protocols.

Predictive factors affecting treatment success in ganglion impar block applied in chronic coccygodynia

BackgroundThis study aimed to determine the predictive factors affecting the success of ganglion impar block applied in chronic coccygodynia.MethodsPatients who received ganglion impar block to treat coccygodynia between January 1,...

The Rationale for Using Neridronate in Musculoskeletal Disorders: From Metabolic Bone Diseases to Musculoskeletal Pain.

Neridronate or ((6-amino-1-hydroxy-1-phosphonohexyl) phosphonic acid) is an amino-bisphosphonate (BP) synthetized in Italy in 1986. Bisphosphonates are molecules with a P-C-P bond in their structure that allows strong and selectively binding to hydroxyapatite (HAP) as well as osteoclasts inhibition through different mechanisms of action. Neridronate was initially used to treat Paget disease of the bone, demonstrating effectiveness in reducing bone turnover markers as well as pain. The interesting molecular properties of neridronate foster its wide use in several other conditions, such as osteogenesis imperfecta, and osteoporosis. Thanks to the unique safety and efficacy profile, neridronate has been used in secondary osteoporosis due to genetic, rheumatic, and oncological diseases, including in pediatric patients. In the last decade, this drug has also been studied in chronic musculoskeletal pain conditions, such as algodystrophy, demonstrating effectiveness in improving extraskeletal outcomes. This review highlights historical and clinical insights about the use of neridronate for metabolic bone disorders and musculoskeletal pain conditions.

A Look at Commonly Utilized Serotonin Noradrenaline Reuptake Inhibitors (SNRIs) in Chronic Pain.

Chronic pain continues to be one of the leading healthcare cost burdens in the United States and is typically defined as ongoing pain, lasting longer than six months. Various treatment options exist for chronic pain, including physical therapy, medical management, pain psychology, and interventional therapies. Pain medications have been the mainstay of treatment for chronic pain conditions with an increasing use of membrane stabilizers and antidepressants to treat neuropathic pain conditions. Specifically, serotonin noradrenaline reuptake inhibitors (SNRIs) have been used to treat a range of pain conditions expanding from everyday use for depressive disorders. SNRIs, including duloxetine, venlafaxine, and milnacipran, have demonstrated efficacy in reducing pain in musculoskeletal pain (chronic low back pain and osteoarthritis), fibromyalgia, and neuropathic pain conditions (peripheral diabetic neuropathy). The article describes the function, role, and use of SNRIs to treat chronic and neuropathic pain by altering the noradrenergic descending inhibitory pathways.

Thalamic Neurometabolite Alterations in Chronic Low Back Pain: A Common Phenomenon across Musculoskeletal Pain Conditions?

A previous study by our group showed that knee osteoarthritis (KOA) patients demonstrate alterations in the thalamic levels of several metabolites, as measured by 1H-magnetic resonance spectroscopy: i.e., higher myo-inositol (mIns), lower N-acetylaspartate (NAA) and lower Choline (Cho), when compared to healthy controls. We sought to replicate these results in a different musculoskeletal pain condition, chronic low back pain (cLBP), and explore whether these metabolites would resolve clinical subtypes of cLBP. Twenty-nine cLBP patients (twenty-two with axial low back pain, cLBPAX, and seven with radicular low back pain, cLBPRAD), and twenty healthy controls were scanned using a conventional PRESS sequence (TE=30ms; TR=1.7s; voxel size=15 × 15 × 15mm) with voxel placement in the left thalamus. Using water-normalized levels, cLBP patients demonstrated higher mIns (p<0.01), lower NAA (p<0.001) and lower Cho (p<0.05) than healthy controls, replicating our prior KOA results in this cLBP cohort. Additionally, NAA was reduced in cLBPAX when compared to cLBPRAD (p<0.05), whereas differences found in Cho and mIns were not statistically significant (p<0.20 and p<0.15, respectively). While pain severity scores were not correlated with metabolite levels, the degree of nociplastic pain, as measured by score on the American College of Rheumatology Fibromyalgia Survey, negatively correlated with NAA. These results suggest that thalamic metabolite changes may be common across spatially different musculoskeletal chronic pain conditions for mIns, a marker of glial dysfunction, NAA, a marker of neuronal integrity, and Cho, a membrane turnover marker. Additionally, the differences between cLBP subtypes suggest that neuronal integrity may have a role to play in the pathophysiology of nociplastic pain. Grant support from 1-R01-NS094306-01A1 (MLL); 1-R01-NS09593701A1 (MLL).

Spanish Translation of the Widespread Pain Index and Symptom Severity Scale for the Diagnosis of Juvenile Fibromyalgia

Juvenile fibromyalgia (JFM) is a chronic musculoskeletal pain condition affecting 2%-6% of school-aged children. Despite its prevalence in pediatric populations, diagnostic resources for JFM are limited. One study validated the widespread pain index (WPI) and symptom severity (SS) scale based on the 2010 American College of Rheumatology (ACR) adult fibromyalgia criteria for JFM among primarily Caucasian adolescents (Ting et al., 2016). However, these patient-report measures are not validated in Spanish and may not be generalizable to Spanish-speaking populations. To date, one study has validated the 2010 ACR criteria among adult Spanish speakers (Segura-Jimenez et al., 2014), yet there was no formal description of the translation process and youth were not included. This study aimed to develop a Spanish version of the WPI and SS scale for the diagnosis of JFM using a culturally sensitive translation methodology. The translation guidelines from the ISPOR task force for translation and cultural adaptation (Wild et al., 2005) were utilized in this study. Two native Spanish speakers residing in Spain completed the forward translation of the WPI and SS scale separately and agreed upon one Spanish translation. Then, two native Spanish speakers residing in the United States (U.S.) completed the back translation separately and agreed upon one English translation, considering the heterogeneity in language use existing within Spanish-speaking groups in the U.S. The back-translated measures were sent to forward translators for final revisions and finalized by team consensus. The Spanish version of the WPI and SS questionnaires were successfully translated via ISPOR standards and are ready for cognitive debriefing amongst Spanish-speaking patients to ensure the translated surveys are comprehensible. Considering the controversy surrounding lacking JFM criteria, it is essential that throughout the process of validating future JFM criteria, a culturally sensitive approach is utilized to ensure multilingual surveys are accessible to non-English speaking patients. Grant support from P30 AR076316 NIAMS/NIH (Co-I Kashikar-Zuck).

P181 Musculoskeletal pain and prognosis of acute coronary syndrome and cerebrovascular accident: a linked electronic health record cohort study

Abstract Background/Aims There is some evidence of an increased risk of cardiovascular disease in patients with painful musculoskeletal conditions, but it is unclear if musculoskeletal pain also worsens its prognosis. The aim was to determine whether patients with musculoskeletal pain have poorer prognosis following acute coronary syndrome (ACS) or cerebrovascular accident (CVA). Methods Data were obtained from national primary care electronic health records (Clinical Practice Research Datalink; CPRD) with linkage to hospital admissions and mortality records. Patients aged 45 years and over with ACS or CVA recorded in primary care and as the primary reason for hospital admission within ±30 days were included. Patients were grouped by consultations in primary care for painful musculoskeletal conditions (by recency/severity and by condition) in the 24 months prior to ACS or CVA. Severe musculoskeletal pain was defined as prescription of strong analgesia or relevant secondary care referral in the 6 months before ACS or CVA. Short-term outcomes included length of hospital stay, mortality during admission or within 30 days of discharge, and readmission within 30 days of discharge. Management outcomes included procedures during admission and prescriptions for anti-hypertensives, anti-platelets and anti-coagulants in the 3 months following admission. Longer term outcomes included further ACS or CVA and mortality in those who survived &amp;gt;30 days after discharge. Results There were 171,670 patients with ACS (36% females; median age 70 years) and 138,512 patients with CVA (49% females; median age 76 years); 30% of patients in each cohort consulted for a painful musculoskeletal condition prior to admission for ACS or CVA. An increased prevalence of cardiovascular risk factors was observed for patients with severe musculoskeletal pain compared to those without pain for comorbidities such as obesity (ACS 26% vs 16%, CVA 25% vs 15%), diabetes (ACS 24% vs 17%, CVA 23% vs 17%) and lifestyle characteristics such as current/ex-smoker (ACS 58% vs 52%, CVA 52% vs 46%), respectively. Patients with severe musculoskeletal pain had similar lengths of stay, rates of readmission and further ACS/CVA after adjustment for sociodemographic characteristics and comorbidities than those without musculoskeletal pain. They were more likely to receive a procedure during admission for ACS (adjusted risk ratio [aRR] 1.15, 95% confidence interval [CI] 1.03-1.28). Prescriptions for ACS (severe pain aRR 1.01, 95% CI 1.00-1.02; inflammatory condition aRR 1.01, 95% CI 1.00-1.02) and CVA (inflammatory condition aRR 1.04, 95% CI 1.01-1.06) were higher in the 3 months post-admission for those with musculoskeletal pain. Conclusion Musculoskeletal pain did not independently worsen the prognosis following hospitalisation for incident ACS or CVA. The findings are reassuring, but also highlight the need for closer surveillance due to the complexities of patients with severe musculoskeletal presenting with incident ACS or CVA. Disclosure K.J. Mason: None. K.P. Jordan: None. F.A. Achana: None. J. Bailey: None. Y. Chen: None. M. Frisher: None. A.L. Huntley: None. C.D. Mallen: None. M.A. Mamas: None. M. Png: None. S. Tatton: None. S. White: None. J.J. Edwards: None.

Hand Surgery Patient Perspectives on Medical Cannabis: A Survey of Over 600 Patients

Medical cannabis (MC) has been proposed as a potential addition to multimodal pain management regimens in orthopedics. This study evaluates hand and upper-extremity patient perspectives of MC as a treatment for common orthopedic and musculoskeletal pain conditions. This study also aims to identify the proportion of patients already using MC, perceived barriers to MC use, and opinions on insurance coverage and legality of cannabis. An anonymous cross-sectional survey study was conducted of all patients at least 18 years old presenting from October 2020 to January 2021 to a hand and upper-extremity outpatient clinic. The survey collected information regarding opinion on MC, including use, legality, and willingness to use MC in the future. Medical cannabis was legal in the states where the study was conducted. A total of 679 patients completed the survey (response rate 72.5%). Sixty-eight patients (10.0%) reported currently using MC. Of the 623 patients (90.0%) who reported not currently using MC, 504 (80.9%) would consider using MC for chronic pain, while the remaining 119 (19.1%) would not consider the use of MC for chronic pain. Age was not associated with whether a patient would consider using MC (P= .16) or was already using MC (P= .10). The most identified barrier to MC use was cost, reported as either expensive or not affordable by 477 patients (70.5%). This study found that most patients presenting for hand and upper-extremity complaints would consider using MC (80.9%), and most perceive it as a safe treatment option for common orthopedic conditions. Moreover, 10% of patients reported already using MC. One of the major barriers to MC use is the cost. Most (90.9%) patients support policies for legalization and insurance coverage of MC. Therapeutic Level III.

Working Alliance Inventory (WAI) and its relationship to patient-reported outcomes in painful musculoskeletal conditions

Purpose Therapeutic alliance (TA) has been positively correlated to improvements in patient outcomes. This study examined the Working Alliance Inventory (WAI) relationship with changes in disability and pain intensity for patients receiving physical therapy (PT) treatment for acute and chronic musculoskeletal pain conditions. Methods Fifty participants were dichotomized into success or failure by the minimal clinically important difference (MCID) on region-specific patient-reported outcome measures (PROM) and Numeric Pain Rating Scale (NPRS). Regression and correlation statistics examined the relationship between WAI with change scores and quantity of PT. Independent t-tests compared WAI scores across categorical variables. Results WAI scores were higher for those meeting MCIDs on PROM and NPRS compared to those who did not. WAI scores were significantly correlated with improvement on region-specific outcome measures and NPRS. Regression analysis found the patient rating of the TA to be a positive predictor for improvement on regions specific outcome measures and NPRS. Conclusions Patients who rated the TA higher were more likely to meet the MCID for region-specific disability and pain intensity. Patient ratings of the TA were associated with improved change scores on pain rating and standardized outcome measures during a course of treatment for musculoskeletal pain conditions. Implications for rehabilitation Patients' early rating of the therapeutic alliance (TA) is associated with improvements seen on pain and functional outcomes. Physical therapists should assess the TA and use strategies to enhance the alliance to optimize patient’s experiences with physical therapy.

The relationship between dietary acid load and intensity of musculoskeletal pain condition: A population-based study.

Pain is a globally prevalent problem, and a comprehension of its pathophysiology is important with respect to patient's health. Musculoskeletal pain conditions (MPs) may be associated with physical, lifestyle, and nutrition status, while dietary acid load (DAL) may be inversely associated with musculoskeletal health in adults. This cross‐sectional study consisted of 175 adults experiencing pain. Anthropometric measurements, physical activity (PA), and pain intensity were assessed via specific questionnaires. Dietary data were collected using a 7‐day 24‐h recall. Foods and beverages were analyzed with Nutritionist IV software for extracting the total energy and nutrients. Net endogenous acid production (NEAP) and potential renal acid load (PRAL) were evaluated for assessing the DAL. Linear regression and Spearman correlation were used to investigate the association of exposure and input variables. Linear regression showed a positive relationship between PRAL and NEAP and pain intensity in the crude model. This significant positive relationship remained after adjusting for all confounders. A lower consumption of potassium, magnesium, vitamin B9 and C, and fiber was seen in the following quartiles of PRAL and NEAP. In addition, MPs intensity and PRAL and NEAP had a weak, positive correlation. This study suggests that a higher DAL may be associated with MPs. However, further research is needed.