Leandro Alberto Calazans Nogueira

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.

Lack of confidence in the lower limb: Cognitive Functional Therapy (CFT) for a unilateral loading impairment in chronic non-specific low back pain. Case report

This case report presents the effect of Cognitive Functional Therapy (CFT) in a patient with chronic non-specific low back pain associated with unilateral loading impairment of the left lower limb. The patient believed surgery was the only possible way to treat the cause of the problem. The management of this idea was to change such belief. Manual therapy and active exercises were combined in order to encourage the patient to trust his back and lower limb again. One month and a half after the first appointment, the treatment resulted in complete absence of pain and disability. The patient returned to work and he was able to climb stairs and load his left limb normally.

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.

The relationship between urinary incontinence, pelvic floor muscle strength and lower abdominal muscle activation among women with low back pain

Abstract Purpose: This study aims to compare pelvic floor muscles (PFM) strength and lower abdominal muscle activation in women with low back pain (LBP) and urinary incontinence (UI) or without UI. Methods: Fifty-four women with LBP were assessed. PFM strength was assessed using the modified Oxford scale and lower abdominal muscle activation was evaluated using a pressure biofeedback unit. Lumbar disability and pain intensity were evaluated by self-reported questionnaires. The Mann–Whitney U-test was used to compare the two groups. A correlation analysis was performed between PFM strength and lower abdominal muscle activation and self-reported measures. Results: Our results showed that 31 presented with UI and 23 without. No statistically significant difference was found between groups in PFM strength (median values; with UI = 3; without UI = 3; p = .61) and in lower abdominal muscle activation capacity (median values; with UI = 9mmHg; without UI = 6mmHg; p = .40). PFM weakness was found in both groups. No significant correlation between the strength of PFM and other variables was found. Conclusion: In conclusion, women with LBP showed an insufficient strength of the PFM, regardless of the presence of UI. The degree of PFM strength was not related to lower abdominal muscle activation, lumbar disability or LBP characteristics.

Group pain neuroscience education combined with supervised exercises reduces pain and improves function of Brazilian women with central sensitisation and a low level of education: a single-subject study

Abstract Purpose: The purpose of this single-subject experimental study was to describe the patient’s outcome following pain neuroscience education in combination with therapeutic exercise for Brazilian women with central sensitisation and a low level of education. Methods: Eight Brazilian women with central sensitisation and a low level of education were screened from a total of 57 patients with musculoskeletal disorders in an outpatient physiotherapy department. Twelve sessions were performed, once a week, including group pain education and supervised exercises. The outcome measures of pain intensity, functionality, catastrophizing, kinesiophobia, quality of life, knowledge of pain physiology and global improvement rating were collected pre- and post-intervention. Results: There was an improvement in pain (before median = 8.5, after median = 5.0; Z = −2.032, p = .042) and functionality (before median = 2.5, after median = 5.6; Z = −2.366, p = .018) at post-intervention evaluation measured by the Wilcoxon signed-rank test. A meaningful improvement was observed in global perceived effect. There were no statistically significant differences for other outcomes. Conclusion: Following a combination of pain neuroscience education with therapeutic exercise, Brazilian women with central sensitisation and a low level of education showed pain relief and improved function. Nonetheless, psychosocial factors, knowledge of pain and quality of life did not improve with the intervention.

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.