Felipe José Jandre dos Reis

Measuring the Pain Area: An Intra- and Inter-Rater Reliability Study Using Image Analysis Software.

Pain drawings have frequently been used for clinical information and research. The aim of this study was to investigate intra‐ and inter‐rater reliability of area measurements performed on pain drawings. Our secondary objective was to verify the reliability when using computers with different screen sizes, both with and without mouse hardware. Pain drawings were completed by patients with chronic neck pain or neck–shoulder–arm pain. Four independent examiners participated in the study. Examiners A and B used the same computer with a 16‐inch screen and wired mouse hardware. Examiner C used a notebook with a 16‐inch screen and no mouse hardware, and Examiner D used a computer with an 11.6‐inch screen and a wireless mouse. Image measurements were obtained using GIMP and NIH ImageJ computer programs. The length of all the images was measured using GIMP software to a set scale in ImageJ. Thus, each marked area was encircled and the total surface area (cm2) was calculated for each pain drawing measurement. A total of 117 areas were identified and 52 pain drawings were analyzed. The intrarater reliability between all examiners was high (ICC = 0.989). The inter‐rater reliability was also high. No significant differences were observed when using different screen sizes or when using or not using the mouse hardware. This suggests that the precision of these measurements is acceptable for the use of this method as a measurement tool in clinical practice and research.

Influence of Hamstring Tightness in Pelvic, Lumbar and Trunk Range of Motion in Low Back Pain and Asymptomatic Volunteers during Forward Bending.

Study Design Cross-sectional study. Purpose To verify the association of hamstring tightness and range of motion in anterior pelvic tilt (PT), lumbar motion (LM), and trunk flexion (TF) during forward bending. Overview of Literature Increased hamstring stiffness could be a possible contributing factor to low back injuries. Clinical observations have suggested that hamstring tightness influences lumbar pelvic rhythm. Movement restrictions or postural asymmetry likely lead to compensatory movement patterns of the lumbar spine, and subsequently to increased stress on the spinal soft tissues and an increased risk of low back pain (LBP). Methods Hamstring muscle tightness was measured using the self-monitored active knee extension (AKE) test. A bubble inclinometer was used to determine the range of motion of PT, LM, and TF during forward bending. Statistical analysis included descriptive statistics, comparisons between groups and a correlation between hamstring tightness (AKE) and anterior PT, TF, and regional LM with p≤0.05. Results The LBP group was composed of 36 participants, and the asymptomatic group consisted of 32 participants. The mean for PT in the control group was 66.7°, 64.5° for LM and 104.6° for TF. Respective values in the symptomatic group were 57.0°, 79.8°, and 82.2°. Conclusions Participants with LBP showed restriction in the pelvis and TF range of motion, but had higher amplitudes in the lumbar spine during forward bending.

Chronic low back pain and disability in Brazilian jiu-jitsu athletes

OBJECTIVES To identify the prevalence of chronic low back pain (CLBP) and functional disability in Brazilian jiu-jitsu athletes. STUDY DESIGN Cross-sectional, observational. SETTINGS The study was conducted at jiu-jitsu training sites in the State of Rio de Janeiro. MAIN OUTCOME MEASURES Presence of Chronic low back pain and Quebec Back Pain Disability Scale. RESULTS The sample was composed of 72 athletes (mean age of 26.7), being 36 recreational and 36 professional. Chronic low back pain was present in 80.6% of athletes. Pain was present in 88.9% of professional and 72.2% of recreational athletes. In the professional jiu-jitsu group, the median of the Quebec Back Pain Disability Scale (QBPDS) was 10 (IQR = 16), and in the recreational group the QBPDS result was 6.0 (IQR = 12) (p = .001). Professional athletes had a marginally significant increased risk of developing CLBP [OR = 3.0; CI(95%) 0.8-10.9)]. CONCLUSION The prevalence of low back pain in jiu-jitsu practice was high and professional athletes seem to have a high risk of developing CLBP.

Pain and Its Consequences in Quality of Life: A Study with WHOQOL-Bref in Leprosy Patients with Neuropathic Pain

Chronic neuropathic pain emerges as a challenge in the treatment of leprosy patients after multidrug therapy discharge. The aim of this study was to determine the quality of life and its repercussions in leprosy patients with chronic pain. We studied male and female patients with chronic neuropathic pain in the last year. Neuropathic pain was confirmed using Douleur Neuropathique en 4 (DN4) and its intensity evaluated by visual analogue scale (VAS). A general questionnaire was applied to evaluate quality of life (WHOQOL-bref). Statistical analyses were composed by descriptive and central tendency. Spearman correlation was used to identify the relation between pain intensity, quality of life domains, and facets. Multiple linear regressions were performed to verify the influence of pain intensity on each facet. Neuropathic pain patients scored worst in physical and environment domains. The low facets were related to pain and discomfort, thinking and concentration, sexual activity, and recreation opportunities. Pain intensity has a high negative influence on psychological domain and recreation opportunities. These findings should contribute to the development of rehabilitation programs considering patients needs to improve their quality of life and true social reintegration.

Central sensitization patients present different characteristics compared with other musculoskeletal patients: A case–control study

Abstract The aims of this study were to identify the prevalence of a clinical dominance of musculoskeletal pain type and to compare pain characteristics among patients with musculoskeletal disorders. A case-sectional study was conducted at a physiotherapy outpatient service in 149 consecutive patients with complaints of musculoskeletal pain. Participants completed a sociodemographic and pain characteristics questionnaire. The dominance of nociceptive (NO), peripheral neuropathic (PN) and central sensitization (CS) mechanisms of musculoskeletal pain was based on clinical classification. The most prevalent clinical predominance was NO pain (53.57%), followed by PN (25.00%) and CS (21.43%). Age, gender and sedentary behaviour did not show differences between pain groups. Patients with CS predominance had a higher number of separated areas (CS 8.1 vs NO 3.0 vs PN 4.9; p < 0.001) and widespread pain (CS 0.52 cm2 vs NO 0.14 cm2 vs PN 0.28 cm2; p = 0.001). Patients with CS predominance had an average pain intensity of 7.90, and the majority of patients were classified as having severe pain. In conclusion, patients with a predominance of CS pain showed higher pain intensity, pain duration and number of pain areas and more widespread pain than those with PN and NO. Chronicity of pain is not sufficient to distinguish CS predominance.

Association between pain drawing and psychological factors in musculoskeletal chronic pain: A systematic review

ABSTRACT Background: It has been speculated that there is an association between pain area and psychological factors in chronic musculoskeletal pain conditions; however, this relation is not well established. Purpose: To investigate the association between pain distribution and psychological factors in chronic musculoskeletal pain conditions. Study Design: Systematic review. Methods: We searched the following databases using optimized search strategies: MEDLINE, PsycINFO, Scopus, Web of Science and Cochrane. Studies were included if they investigated the relation between pain area using a pain drawing (PD) and psychological factors measured by any consistent available method. Results: Eleven articles were included. A total of 1301 participants with different musculoskeletal pain conditions, including low back pain, whiplash-associated disorders and fibromyalgia took part in the studies. In three studies, the correlation between pain area and depression was weak (r = 0.15, p = N/A; r = 0.26, p < 0.05; r = 0.25, p = 0.01). Depression seemed to be a risk factor for pain in more body areas in one study (relative risk = 6.09, 95% CI = 1.1–33.5; p < 0.05). The relation between pain area and other psychological factors such as anxiety, kinesiophobia, catastrophizing, memory disturbances and concentration difficulties was also reported. Conclusions: A definitive answer on the relation of psychological factors and pain area is not available; the findings suggest that only depression might have a weak relation with pain area. Future studies that investigate sensory, psychological, emotional, cognitive and behavioral aspects, and also more accurate methods of PD assessment, are needed.

Avaliação da limitação das atividades diárias e qualidade de vida de pacientes com hanseníase submetidos à cirurgia de neurólise para tratamento das neurites

La neurolisis es indicada para reducir el sufrimiento neural e impedir la instalacion de secuelas e incapacidades en pacientes con lepra. El objetivo de este estudio fue verificar el grado de limitacion de las actividades de la vida diaria y la calidad de vida de pacientes con lepra sometidos a neurolisis para el tratamiento de las neuritas. Participaron del estudio los pacientes sometidos a neurolisis en el periodo de 1998 a 2011. Fueron recolectadas informaciones sociodemograficas y clinicas, limitaciones de las actividades (SALSA) y la calidad de vida (WHOQOL-bref). Los analisis estadisticos incluiran la frecuencia, las medidas de tendencia central y dispersion, los tests de Mann-Whitney, Kruskall-Wallis y los coeficientes de correlacion de Spearman adoptando p<0,05. La muestra fue compuesta por 36 pacientes con edad media de 44,0 anos y 3 anos de post-operatorio. Seis pacientes presentan grado 0 de incapacidad, 18 grado 1 y 12 grado 2. La principal diferencia en la escala SALSA ocurrio entre el grado 0 (media=31,8) y el grado 1 (media=42,56). Los valores obtenidos en el analisis de WHOQOL-bref incluyen los dominios fisico (media 11,10); psicologico (media 13,41); relaciones sociales (media 15,15); medio ambiente (media 11,63). Las facetas del WHOQOL-bref mas comprometidas fueron la capacidad para el trabajo; sentimientos negativos (psicologico); actividad sexual (relaciones sociales); recursos financieros (medio ambiente). A pesar de la realizacion de la neurolisis, la mayor parte de los integrantes presentaron limitaciones en las actividades, siendo mayor en aquellos con incapacidades fisicas. La mayor insatisfaccion en la calidad de vida fue en el dominio fisico, principalmente en los que se refiere al dolor y la necesidad de cuidados de salud.

Evaluation of the limitations in daily-life activities and quality of life in leprosy ­patients submitted to surgical neurolysis to treat neuritis

La neurolisis es indicada para reducir el sufrimiento neural e impedir la instalacion de secuelas e incapacidades en pacientes con lepra. El objetivo de este estudio fue verificar el grado de limitacion de las actividades de la vida diaria y la calidad de vida de pacientes con lepra sometidos a neurolisis para el tratamiento de las neuritas. Participaron del estudio los pacientes sometidos a neurolisis en el periodo de 1998 a 2011. Fueron recolectadas informaciones sociodemograficas y clinicas, limitaciones de las actividades (SALSA) y la calidad de vida (WHOQOL-bref). Los analisis estadisticos incluiran la frecuencia, las medidas de tendencia central y dispersion, los tests de Mann-Whitney, Kruskall-Wallis y los coeficientes de correlacion de Spearman adoptando p<0,05. La muestra fue compuesta por 36 pacientes con edad media de 44,0 anos y 3 anos de post-operatorio. Seis pacientes presentan grado 0 de incapacidad, 18 grado 1 y 12 grado 2. La principal diferencia en la escala SALSA ocurrio entre el grado 0 (media=31,8) y el grado 1 (media=42,56). Los valores obtenidos en el analisis de WHOQOL-bref incluyen los dominios fisico (media 11,10); psicologico (media 13,41); relaciones sociales (media 15,15); medio ambiente (media 11,63). Las facetas del WHOQOL-bref mas comprometidas fueron la capacidad para el trabajo; sentimientos negativos (psicologico); actividad sexual (relaciones sociales); recursos financieros (medio ambiente). A pesar de la realizacion de la neurolisis, la mayor parte de los integrantes presentaron limitaciones en las actividades, siendo mayor en aquellos con incapacidades fisicas. La mayor insatisfaccion en la calidad de vida fue en el dominio fisico, principalmente en los que se refiere al dolor y la necesidad de cuidados de salud.

Trial Protocol: Cognitive functional therapy compared with combined manual therapy and motor control exercise for people with non-specific chronic low back pain: protocol for a randomised, controlled trial

INTRODUCTION Chronic low back pain is a public health problem, and there is strong evidence that it is associated with a complex interaction of biopsychosocial factors. Cognitive functional therapy is an intervention that deals with potentially modifiable multidimensional aspects of pain (eg, provocative cognitive, movement and lifestyle behaviours). There is evidence (from a single randomised, controlled trial) that cognitive functional therapy is better than combined manual therapy and motor control exercise. However, this study had significant methodological shortcomings including the failure to carry out an intention-to-treat analysis and a considerable loss of follow-up of participants. It is important to replicate this study in another domain through a randomised clinical trial with similar objectives but correcting these methodological shortcomings. AIM To investigate the efficacy of cognitive functional therapy compared to combined manual therapy and exercise on pain and disability at 3 months in patients with chronic non-specific low back pain. DESIGN Two-group, randomised, multicentre controlled trial with blinded assessors. PARTICIPANTS AND SETTINGS One hundred and forty-eight participants with chronic low back pain that has persisted for >3months and no specific spinal pathology will be recruited from the school clinic of the Centro Universitário Augusto Motta and a private clinic in the city of Rio de Janeiro, Brazil. INTERVENTION A Four to 10 sessions of cognitive functional therapy. The physiotherapists who will treat the participants in the cognitive functional therapy group have previously attended 2 workshops with two different tutors of the method. Such physiotherapists have completed 106 hours of training, including workshops and patient examinations, as well as conducting a pilot study under the supervision of another physiotherapist with>3 years of clinical experience in cognitive functional therapy. INTERVENTION B Four to 10 sessions of combined manual therapy and motor control exercises. Participants in the combined manual therapy and exercise group will be treated by two physiotherapists with an average of >10years of clinical experience in manual therapy and motor control exercises, including isolated contractions of the deep abdominal muscles. MEASUREMENTS The primary outcome measures will be pain intensity and disability 3 months after randomisation. Secondary outcomes will be pain and disability assessed 6 and 12 months after randomisation, and both global perceived effect and patient satisfaction at 3, 6 and 12 months after randomisation. The potential outcome mediators will be assessed at 3 and 6 months after randomisation, with brief screening questions for anxiety, social isolation, catastrophisation, depression, fear of movement, stress and sleep. Non-specific predictors and moderators will include age, gender, duration of chronic low back pain, chronicity risk (Örebro and Start Back score), number of pain areas, stressful life event, MRI scan imaging, and family history. ANALYSIS Intention-to-treat analysis will be performed. Linear mixed models will be used to compare the mean differences in pain intensity, disability and global perceived effect between the intervention arms. The analysis of the effect of potential mediators of the treatment will be performed using the causal mediation methods described by Imai and colleagues. The baseline variables will be evaluated as predictors and moderators of treatment, including terms and interaction models. A level of statistical significance of 5% will be used in the analysis. All the analyses will be performed using RStudio. SIGNIFICANCE This study will investigate whether the results of the first cognitive functional therapy randomised clinical trial are reproducible. The present study will have a sample size capable of detecting clinically relevant effects of the treatment with a low risk of bias. In pragmatic terms, this clinical trial is designed to reproduce the intervention as it would be performed in clinical practice by a trained physiotherapist who works with cognitive functional therapy, which increases the relevance of this study. The combined manual therapy and exercise group comprises an intervention strategy widely used by physiotherapists to treat low back pain. As evidence of efficacy is still limited, the results of a randomised, controlled clinical trial of high methodological quality will help physiotherapists in clinical decision-making.

Cognitive Functional Therapy (CFT) for chronic non-specific neck pain

This case report presents the effect of Cognitive Functional Therapy (CFT) in a patient with chronic non-specific neck pain. The patient believed that pain signified tissue damage, and demonstrated pain catastrophizing, hypervigilance, stress sensitivity, and movement impairment of the neck, during extension and rotation. The CFT intervention integrated a cognitive approach with manual therapy and active exercises to encourage the patient to trust her neck again. One month after the first appointment, the patient had recovered confidence, and the pain and disability had disappeared almost entirely.