Effect of two contrasting types of physical exercise on chronic neck muscle pain. Assessing chronic pain in general practice: Are guidelines relevant? A cluster randomized controlled trial A systematic review of randomized controlled trials on exercise parameters in the treatment of patellofemoral pain: what works? A physiotherapist-delivered integrated exercise and pain coping skills training intervention for individuals with knee osteoarthritis: a randomised controlled trial protocol Design of clinical trials for biomarker research in oncology. A Randomized, Controlled Trial of Manual Therapy and Specific Adjuvant Exercise for Chronic Low Back Pain Pilates exercises improve low back pain and quality of life in patients with HTLV-1 virus: a randomized crossover clinical trial. Effectiveness of physical training for self-employed persons with musculoskeletal disorders: a randomized controlled trial Developing Effective and Efficient care pathways in chronic Pain: DEEP study protocol A Randomized Clinical Trial of Treatment for Lumbar Segmental Rigidity Multidisciplinary Group Rehabilitation Versus Individual Physiotherapy for Chronic Nonspecific Low Back Pain: A Randomized Trial Supervised Exercise With and Without Spinal Manipulation Performs Similarly and Better Than Home Exercise for Chronic Neck Pain: A Randomized Controlled Trial Epidural Interferon Gamma-Immunoreactivity: A Biomarker for Lumbar Nerve Root Irritation Stretch Exercises Increase Tolerance to Stretch in Patients With Chronic Musculoskeletal Pain: A Randomized Controlled Trial Effects of expectancies and coping on pain-induced motivation to smoke. Diagnostic utility of facet (zygapophysial) joint injections in chronic spinal pain: a systematic review of evidence. The effect of motor control exercise versus placebo in patients with chronic low back pain [ACTRN012605000262606] Reporting of Sex Effects by Systematic Reviews on Interventions for Depression, Diabetes, and Chronic Pain Biomarkers of a five-domain translational substrate for schizophrenia and schizoaffective psychosis Decrease in musculoskeletal pain after 4 and 12 months of an aerobic exercise intervention: a worksite RCT among cleaners The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews Depression and osteoarthritis. Early intervention for adolescents with Patellofemoral Pain Syndrome - a pragmatic cluster randomised controlled trial
OBJECTIVE The prevalence of neck muscle pain has steadily increased and especially pain from the descending part of the trapezius muscle has been associated with monotonous work tasks such as computer work . Physical exercise is generally recommended as treatment , but it is unclear which type of training is most effective . Our objective was to determine the effectiveness of specific strength training of the painful muscle versus general fitness training without direct involvement of the painful muscle ( leg bicycling ) on work-related neck muscle pain . METHODS We conducted a r and omized controlled trial and recruited subjects from 7 workplaces characterized by monotonous jobs ( e.g. , computer-intensive work ) . Forty-eight employed women with chronic neck muscle pain ( defined as a clinical diagnosis of trapezius myalgia ) were r and omly assigned to 10 weeks of specific strength training locally for the affected muscle , general fitness training performed as leg bicycling with relaxed shoulders , or a reference intervention without physical activity . The main outcome measure was an acute and prolonged change in intensity of neck muscle pain ( 100-mm visual analog scale [ VAS ] ) . RESULTS A decrease of 35 mm ( approximately 79 % ; P<0.001 ) in the worst VAS pain score over a 10-week period was seen with specific strength training , whereas an acute and transient decrease in pain ( 5 mm ; P<0.05 ) was found with general fitness training . CONCLUSION Specific strength training had high clinical relevance and led to marked prolonged relief in neck muscle pain .  General fitness training showed only a small yet statistically significant acute pain reduction Objectives : To evaluate the impact of using pain assessment scales on the management of musculoskeletal chronic pain . Methods : Cluster-r and omized controlled multicentre trial in French general practice setting s. Practice s were r and omized by region before patient recruitment . The inclusion concerned patients suffering from musculoskeletal chronic pain . General practitioners assigned to the scale group used two vali date d assessment instruments ; those assigned to the control group cared for their patients according to their usual practice . The primary end-point was the level of relief obtained and the secondary changes in prescription of painkilling modalities . Results : A total of 155 general practitioners included 772 successive patients suffering from musculoskeletal chronic pain . The control group reported a mean level of relief of 50.7 % compared with one of 41.1 % in the scale group ( p<0.0001 ) . In the intervention group , physicians decreased significantly their prescription of  level two painkillers .  Conclusions . In general practice , the use of pain assessment scales is not associated with greater pain relief . The lesser level of pain relief obtained in the scale group does provide evidence that using pain assessment scales does not enhance the relief of chronic pain in patients in primary care . Guidelines which recommend the systematic use of scales for the assessment and monitoring of chronic pain are not tailored to either the context or the patients encountered in the primary care setting Purpose There is research evidence which supports the effectiveness of exercise in reducing pain and increasing function in patients with patellofemoral pain syndrome . However , what is unclear are the parameters underpinning this intervention . This has led to uncertainty when operationalizing exercises for patients with patellofemoral pain syndrome in clinical practice . The aim of this review was to evaluate the parameters of exercise programs reported in primary research , to provide clinicians with evidence -based recommendations for exercise prescription for patellofemoral pain . Methods A systematic review of r and omized controlled trials was undertaken . Only trials that identified exercise to be effective in treating patellofemoral pain were included . Appropriate data bases and reference lists were search ed using established keywords . Data relating to common exercise parameters such as the type of exercise , length , and frequency of intervention , intensity , repetitions , sets , and specific technique were extracted , along with details of co- interventions that may have been used . Results A total of ten r and omized controlled trials were included in this review and from these trials 14 interventions arms were evaluated . All 14 interventions focused on active exercises , all but two of which also included a passive stretching component . The current body of evidence demonstrates positive results with exercise interventions such as  knee extension , squats , stationary cycling , static quadriceps , active straight leg raise , leg press , and step-up and down exercises  for patients with patellofemoral pain syndrome . A progressive regime of daily exercises of two to four sets of ten or more repetitions over an intervention period of 6 weeks or more , combined with exercises to address flexibility of the lower limb musculature was commonly used . Conclusion Currently , the primary research on this topic supports the use of closed kinetic chain , strengthening exercises for musculature of the lower limb , combined with flexibility options . The current evidence base supports a prescription of daily exercises of two – four sets of ten or more repetitions over a period of 6 weeks or more Background Knee osteoarthritis ( OA ) is a prevalent chronic musculoskeletal condition with no cure . Pain is the primary symptom and results from a complex interaction between structural changes , physical impairments and psychological factors . Much evidence supports the use of strengthening exercises to improve pain and physical function in this patient population . There is also a growing body of research examining the effects of psychologist-delivered pain coping skills training ( PCST ) particularly in other chronic pain conditions . Though typically provided separately , there are symptom , re source and personnel advantages of exercise and PCST being delivered together by a single healthcare professional . Physiotherapists are a logical choice to be trained to deliver a PCST intervention as they already have expertise in administering exercise for knee OA and are cognisant of the need for a biopsychosocial approach to management . No studies to date have examined the effects of an integrated exercise and PCST program delivered solely by physiotherapists in this population . The primary aim of this multisite r and omised controlled trial is to investigate whether an integrated 12-week PCST and exercise treatment program delivered by physiotherapists is more efficacious than either program alone in treating pain and physical function in individuals with knee OA . Methods / design This will be an assessor-blinded , 3-arm r and omised controlled trial of a 12-week intervention involving 10 physiotherapy visits together with home practice . Participants with symptomatic and radiographic knee OA will be recruited from the community in two cities in Australia and r and omized into one of three groups : exercise alone , PCST alone , or integrated PCST and exercise .  R and omisation will be stratified by city ( Melbourne or Brisbane ) and gender . Primary outcomes are overall average pain in the past week measured by a Visual Analogue Scale and physical function measured by the Western Ontario and McMaster Universities Osteoarthritis Index subscale . Secondary outcomes include global rating of change , muscle strength , functional performance , physical activity levels , health related quality of life and psychological factors . Measurements will be taken at baseline and immediately following the intervention ( 12 weeks ) as well as at 32 weeks and 52 weeks to examine maintenance of any intervention effects . Specific assessment of adherence to the treatment program will also be made at weeks 22 and 42 . Relative cost-effectiveness will be determined from health service usage and outcome data . Discussion The findings from this r and omised controlled trial will provide evidence for the efficacy of an integrated PCST and exercise program delivered by physiotherapists in the management of painful and functionally limiting knee OA compared to either program alone . Trial registration Australian New Zeal and Clinical Trials Registry reference number : The developmental pathway from discovery to clinical practice for biomarkers and biomarker-directed therapies is complex . While several issues need careful consideration , two critical issues that surround the validation of biomarkers are the choice of clinical trial design ( which is based on the strength of the preliminary evidence and marker prevalence ) and the biomarker assay related issues surrounding the marker assessment methods such as the reliability and reproducibility of the assay . This review focuses on trial design s for marker validation , both in the setting of early phase trials for initial validation , as well as in the context of larger definitive trials . Design s for biomarker validation are broadly classified as retrospective ( i.e. , using data from previously well-conducted , r and omized , controlled trials ) or prospect i ve ( enrichment , allcomers or adaptive ) . We believe that the systematic evaluation and implementation of these design strategies are essential to accelerate the clinical validation of biomarker-guided therapy , thereby taking us a step closer to the goal of personalized medicine Objective : This article examines the effectiveness of manual therapy with specific adjuvant exercise for treating  chronic low back pain and disability .  Methods : A single blind , r and omized , controlled trial was employed . Patients were prescribed an exercise program that was tailored to treat their musculoskeletal dysfunctions or given a nonspecific program of general stretching and aerobic conditioning . In addition , patients received manual therapy or sham manual therapy . Participants were seen for 6 weekly sessions and were asked to perform their exercise program twice daily . Results : Seventy-two out of 100 patients completed the study . Multivariate tests conducted for measures of pain and disability revealed a significant group by time interaction ( P = 0.04 and P = 0.05 , respectively ) , indicating differential change in these measures pretreatment to posttreatment as a function of the treatment received . When controlling for pretreatment scores , patients receiving manual therapy with specific adjuvant exercise reported significant reductions in pain . No change in perceived disability was observed , with the exception that patients receiving sham manual therapy with specific adjuvant exercise reported significantly greater disability at posttreatment . Discussion : Manual therapy with specific adjuvant exercise appears to be beneficial in treating  chronic low back pain .  Despite changes in pain , perceived function did not improve . It is possible that impacting chronic low back pain alone does not address psychosocial or other factors that may contribute to disability . Further studies are needed to examine the long-term effects of these interventions and to address what adjuncts are beneficial in improving function in this population BACKGROUND Low back pain is highly prevalent in patients with HTLV-1 . The effects of physical activity on this condition are not known , but postural misalignment and motor deficits are frequently present . OBJECTIVES To assess the effect of Pilates exercises on chronic low back pain in these patients , and its impact on quality of life . METHODS A r and omized crossover clinical trial was conducted , involving 22 patients from a reference center in Salvador , Bahia , Brazil . The VAS was used to evaluate the effect of Pilates on pain intensity and the SF-36 to assess its impact on quality of life . RESULTS Our results provide evidence of positive effects on pain intensity and almost all domains of quality of life when patients followed the Pilates exercise program described . CONCLUSION The Pilates method may be a useful tool in alleviating the symptoms of low back pain , and had a significant impact on quality of life in this sample of patients Background Despite the fact that the population of self-employed persons is still growing and at risk for long term disability due to a number of risk factors , there is still a lack of information on the effectiveness of interventions for this specific group . Methods To determine the effectiveness of physical training without a cognitive behavioral component and workplace specific exercises ( PT ) and physical training with a cognitive behavioral component and workplace specific exercises ( PTCBWE ) , we conducted a pragmatic R and omized Controlled Trial , stratified into two groups . Self-employed persons with a new work disability cl aim because of musculoskeletal disorders were r and omized to PT ( n = 53 ) or PTCBWE ( n = 76 ) , or to a corresponding usual care group ( n = 50 and n = 75 respectively ) . Both types of training consisted of cardiovascular training , strengthening , relaxation and posture exercises and took place two or three times a week , for 1–1.5 hours , during three months , also if someone had already returned to work full-time . The primary outcome measure was cl aim duration ( in days ) during 12 months follow-up . Pain severity and functional status were secondary outcome measures . All data were assessed at baseline and at 6 and 12 months follow-up . The data with regard to cl aim duration were analyzed by survival analysis and Cox regression analysis . Secondary outcome measures were analyzed by means of linear regression analysis . Results After 12 months of follow-up there was no difference in cl aim duration between PT and usual care ( Hazard Ratio 0.7 ; 95%CI , 0.4–1.1 ; p = 0.12 ) or PTCBWE and usual care ( Hazard Ratio 0.9 ; 95%CI , 0.6–1.4 ; p = 0.72 ) . Both types of physical training and usual care  improved in pain and functional status over time , but there was only a statistically significant difference in favor of PT on pain improvement at 6 months . Conclusion In this study , physical training with and without a cognitive behavioral component and workplace specific exercises for self-employed persons with musculoskeletal disorders was not shown to be effective on cl aim duration , pain severity and functional status at 12 months follow-up . Trial registration Current Controlled Trials IS RCT N67766245 Background Pain affecting the face or mouth and lasting longer than three months ( “ chronic orofacial pain ” , COFP ) is relatively common in the UK . This study aims to describe and model current care pathways for COFP patients , identify areas where current pathways could be modified , and model whether these changes would improve outcomes for patients and use re sources more efficiently . Methods / Design The study takes a prospect i ve operations research approach . A cohort of primary and secondary care COFP patients ( n = 240 ) will be recruited at differing stages of their care in order to follow and analyse their journey through care . The cohort will be followed for two years with data collected at baseline 6 , 12 , 18 , and 24 months on : 1 ) experiences of the care pathway and its impacts ; 2 ) quality of life ; 3 ) pain ; 4 ) use of health services and costs incurred ; 5 ) illness perceptions .  Qualitative in-depth interviews will be used to collect data on patient experiences from a purposive sub- sample of the total cohort ( n = 30 ) at baseline , 12 and 24 months . Four separate appraisal groups ( public , patient , clincian , service manager/commissioning ) will then be given data from the pathway analysis and asked to determine their priority areas for change . The proposals from appraisal groups will inform an economic modelling exercise . Findings from the economic modelling will be presented as incremental costs , Quality Adjusted Life Years ( QALYs ) , and the incremental cost per QALY gained . At the end of the modelling a series of recommendations for service change will be available for implementation or further trial if necessary . Discussion The recent white paper on health and the report from the NHS Forum identified chronic conditions as priority areas and whilst technology can improve outcomes , so can simple , appropriate and well-defined clinical care pathways . Underst and ing the opportunity cost related to care pathways benefits the wider NHS . This research develops a method to help design efficient systems built around one condition ( COFP ) , but the principles should be applicable to a wide range of other chronic and long-term conditions Study Design . A r and omized single-blind clinical trial of facet injections plus exercise , versus exercise alone , in chronic disabling work-related lumbar spinal disorders ( CDWRLSD ) , accompanied by pilot interrater reliability and facet syndrome prevalence studies . Objectives . To systematic ally investigate the use of facet injections as an adjunct to supervised lumbar stretching exercises in regaining lumbar range of motion ( ROM ) following prolonged deconditioning after work-related lumbar injuries . To assess interrater reliability of visual assessment of segmental rigidity ( SR ) , and to evaluate the prevalence of facet syndrome in cases of lumbar SR . Summary of Background Data . Corticosteroid joint injections have often been used to reduce musculoskeletal inflammation to facilitate joint mobilization in the presence of degenerative arthritis . Lumbar segmental rigidity is a recently described entity usually associated with painful chronic spinal disorders and postoperative spine surgery . Previous work has shown that SR and lumbar ROM improves with a brief intervention consisting of facet injections followed by specific stretching exercises . No systematic study has investigated the potential benefits of a combination of facet injections and exercise over supervised exercises alone to treat lumbar SR . Similarly , no study has assessed the association between SR and the facet syndrome . Methods . From a group of consecutive patients ( n = 421 ) with CDWRLSD referred for tertiary rehabilitation between November 1999 and January 2001 , 70 were noted to have SR on intake physical examination . The first part of this study assessed interrater reliability for detecting SR , and intrarater reliability for 3-segment true lumbar ROM measurements . Patients r and omly assigned to participate in supervised stretching exercises with the addition of fluoroscopically guided bilateral facet injections at the involved levels ( Group A , n = 36 ) also underwent facet syndrome prevalence assessment at the time of injection . They were compared to a r and omly allocated comparison group ( Group B , n = 34 ) undergoing exercises alone in a single-blind design . Physical therapists saw patients an average of twice per week , providing supervision of a progressive home stretching program . Inclinometric joint ROM was measured at the time of group allocation , and again 5 to 7 weeks later . Vali date d question naires of pain ( intensity VAS ) and disability ( Million VAS ) related to the CDWRLSD were provided before and after the interventions . Results . Part 1 reliability and facet syndrome prevalence work revealed that interrater reliability for experienced examiners to detect rigid segments was excellent ( Pearson ’s r = 0.97 , P < 0.01 ) . Intrarater 3-joint motion measurement reliability was also good for all sagittal/coronal ROM ( Pearson ’s r = 0.95–0.99 , P < 0.01 ) . Only 5 of 29 subjects with SR met criteria for facet syndrome ( 17 % ) , consistent with prior prevalence studies of unselected patients with low back pain . In Part 2 , a large majority of patients in both groups improved from the initial to the post-treatment ROM measurements ( the primary outcome criterion of the study ) . However , a higher proportion of Group A ( injection ) patients ( 87%–95 % ) showed ROM improvement , compared to Group B ( exercise only ) patients ( 64%–79 % ) . Group A patients showed a significantly greater ROM improvement in all sagittal and coronal movements , both in absolute terms and percent of initial measurement . No significant differences in pain or disability self-report were found between groups , pre- or postintervention , but both groups showed significant improvement from pre- to postintervention in pain and disability assessment s. Conclusions . The detection of SR and measurement of 3-segment true lumbar ROM by experienced examiners is highly reliable . Only 17 % of CDWRLSD patients with lumbar SR met criteria for the facet syndrome , a rate approximately equal to that of unselected low back pain cohorts . This indicates that lumbar SR may be found whether or not pain of facet joint origin is present . In the r and omized trial , facet injections significantly increased the percentage of patients with SR showing ROM improvement , as well as the degree of improvement in lumbar mobility after treatment . There is no evidence that facet injections increase the improvements in pain/disability report noted in both groups Study Design . A r and omized trial . Objective . To evaluate the effectiveness of a semi-intensive multidisciplinary rehabilitation for patients with chronic low back pain in an outpatient setting . Summary and Background Data . Systematic review s have shown that there is strong evidence that intensive multidisciplinary treatment ( > 100 hours ) , which includes functional restoration , improves function among chronic patients with low back pain , and moderate evidence that it reduces pain but contradictory evidence regarding improvement of working ability . However , there is paucity of data whether semi-intensive outpatient multidisciplinary rehabilitation in groups is more effective than individual physiotherapy . Material s and Methods . A total of 120 women employed as healthcare and social care professionals with nonspecific chronic low back pain were recruited from two occupational healthcare centers . The patients were r and omized into two intervention programs . Multidisciplinary rehabilitation ( n = 59 ) was conducted in groups and comprised of physical training , workplace interventions , back school , relaxation training , and cognitive-behavioral stress management methods for 70 hours . The individual physiotherapy ( n = 61 ) included physical exercise and passive treatment methods administered for 10 hours . Main outcome measures were : back pain and sciatic pain intensity , disability , sick leaves , healthcare consumption , symptoms of depression , and beliefs of working ability after 2 years . Results . There were no statistically significant differences between the two treatment groups in main outcome measures just after rehabilitation , at 6- , at 12- , or 24-month follow-up . In both intervention arms , however , the before- and -after comparison showed favorable effects , and the effects were still maintained at 2 years follow-up . Conclusions . The results of this study indicate that semilight outpatient multidisciplinary rehabilitation program for female chronic low back pain patients does not offer incremental benefits when compared with rehabilitation carried out by a physiotherapist having a cognitive-behavioral way of administering the treatment Study Design . R and omized controlled trial using mixed methods . Objective . To evaluate the relative effectiveness of high-dose supervised exercise with and without spinal manipulation and low-dose home exercise for  chronic neck pain .  Summary of Background Data . Neck pain is a common global health care complaint with considerable social and economic impact . Systematic review s have found exercise therapy ( ET ) to be effective for neck pain , either alone or in combination with spinal manipulation . However , it is unclear to what extent spinal manipulation adds to supervised exercise or how supervised high-dose exercise compares with low-dose home exercise . Methods . Two hundred and seventy patients with chronic neck pain were studied at an outpatient clinic . Patients were r and omly assigned one of the following interventions : ( 1 ) high-dose supervised strengthening exercise with spinal manipulation ( exercise therapy combined with spinal manipulation therapy [ ET + SMT ] ) , ( 2 ) high-dose supervised strengthening exercise ( ET ) alone , or ( 3 ) low-dose home exercise and advice ( HEA ) . The primary outcome was patient-rated pain at baseline and at 4 , 12 , 26 , and 52 weeks . Secondary measures were disability , health status , global perceived effect , medication use , and satisfaction . Results . At 12 weeks , there was a significant difference in patient-rated pain between ET + SMT and HEA ( 1.3 points , P < 0.001 ) and ET and HEA ( 1.1 points , P = 0.001 ) . Although there were smaller group differences in patient-rated pain at 52 weeks ( ET + SMT vs. HEA , 0.2 points , P > 0.05 ; ET vs. HEA , 0.3 points , P > 0.05 ) , linear mixed model analyses incorporating all time points yielded a significant advantage for the 2 supervised exercise groups ( ET + SMT vs. HEA , P = 0.03 ; ET vs. HEA , P = 0.02 ) . Similar results were observed for global perceived effect and satisfaction . Conclusion . Supervised strengthening exercise with and without spinal manipulation performed similarly , yielding better outcomes than home exercise particularly in the short term . Various stakeholders ' perspectives should be considered carefully when making recommendations regarding these therapies , taking into account side effects , preferences , and costs Study Design . Prospect i ve observational cohort . Objective . Correlate epidural inflammatory cytokines with the clinical response to  epidural steroid injection  in patients with lumbar nerve root irritation . Summary of Background Data . Some back pain syndromes are thought to be associated with activation of inflammatory pathways and others may be associated with primary mechanical derangements . Human studies providing detailed evidence for the primary inflammatory causation , which may be best treated with anti-inflammatory strategies , are lacking . There are currently no accurate diagnostic tests to predict the response to epidural steroid injection or surgical intervention in back pain and sciatica syndromes . Methods . Forty-seven consecutive patients with lumbar degenerative changes and low back and /or leg pain were prospect ively enrolled . An epidural lavage was performed , followed by injection of marcaine/depo-medrol . Subjects scored their pain before and 3 months after the procedure . The immunoreactivity of an array of cytokines was measured in lavage sample s and compared with clinical response to the therapeutic injection . Ten subjects underwent repeat epidural lavage sampling 3 months after the steroid injection . Results . Interferon gamma ( IFN&ggr ; ) was the most consistently detected cytokine . IFN&ggr;-immunoreactivity also highly correlated with reported reduction of pain 3-months after the epidural steroid injection . In subjects reporting significant pain relief ( > 50 % ) from the injection , mean [ IFN&ggr ; ] was significantly greater compared with patients experiencing no significant relief . The IFN&ggr;-immunoreactivity in repeat lavage sample s decreased to trace residual concentrations in patients who reported pain relief from the steroid injection . Conclusion . The presence of epidural IFN&ggr;-immunoreactivity corresponding to > 10 pg/mL predicted significant pain relief after epidural steroid injection with > 95 % accuracy . These results suggest that IFN&ggr ; may be part of a biochemical cascade triggering pain in sciatica ; IFN&ggr;-immunoreactivity may aid as a biomarker for predicting the response to steroid therapy and /or surgical intervention , and may serve as a future therapeutic target Background : Stretch is commonly prescribed as part of physical rehabilitation in pain management programs , yet little is known about its effectiveness . Objective : A r and omized controlled trial was conducted to investigate the effects of a 3-week stretch program on muscle extensibility and stretch tolerance in patients with chronic musculoskeletal pain . Design : A within-subject design was used , with one leg of each participant r and omly allocated to an experimental ( stretch ) condition and the other leg r and omly allocated to a control ( no-stretch ) condition . Patients and Setting : Thirty adults with pain of musculoskeletal origin persisting for at least 3 months were recruited from patients enrolled in a multidisciplinary pain management program at a hospital in Sydney , Australia . Intervention : The hamstring muscles of the experimental leg were stretched daily for 1 minute over 3 weeks ; the control leg was not stretched . This intervention was embedded within a pain management program and supervised by physical therapists . Measurements : Primary outcomes were muscle extensibility and stretch tolerance , which were reflected by passive hip flexion angles measured with st and ardized and nonst and ardized torques , respectively . Initial measurements were taken before the first stretch on day 1 , and final measurements were taken 1 to 2 days after the last stretch . A blinded assessor was used for testing . Results : Stretch did not increase muscle extensibility ( mean between-group difference in hip flexion was 1 ° , 95 % confidence interval=−2 ° to 4 ° ) , but it did improve stretch tolerance ( mean between-group difference in hip flexion was 8 ° , 95 % confidence interval=5 ° to 10 ° ) . Conclusion : Three weeks of stretch increases tolerance to the discomfort associated with stretch but does not change muscle extensibility in patients with chronic musculoskeletal pain The prevalence of tobacco smoking  among persons with recurrent pain is approximately twice that observed in the general population . Smoking has been associated with the development and exacerbation of several chronically painful conditions . Conversely , there is both experimental and cross-sectional evidence that pain is a potent motivator of smoking . A recent study provided the first evidence that laboratory-induced pain could elicit increased craving and produce shorter latencies to smoke ( Ditre & Br and on , 2008 ) . To further eluci date interrelations between pain and smoking , and to identify potential targets for intervention , in the current study , we tested whether several constructs derived from social-cognitive theory influence the causal pathway between pain and increased motivation to smoke .  Smokers ( N = 132 ) were r and omly assigned to 1 of 4 conditions in this 2 x 2 between-subjects experimental design . Results indicated that manipulations design ed to ( a ) challenge smoking-related outcome expectancies for pain reduction and ( b ) enhance pain-related coping produced decreased urge ratings and increased latencies to smoke , relative to controls . An unexpected interaction effect revealed that although each manipulation was sufficient to reduce smoking urges , the combination was neither additive nor synergistic . These findings were integrated with those of the extant literature to conceptualize and depict a causal pathway between pain and motivation to smoke as moderated by smoking-related outcome expectancies and mediated by the use of pain coping behaviors BACKGROUND Chronic refractory spinal pain poses a peculiar diagnostic challenge because of multiple putative pain sources , overlapping clinical features , and nonspecific radiologic findings . Diagnostic injection techniques are employed to isolate the source ( s ) of pain . Facet or zygapophysial joint pain is an example of spinal pain diagnosed by local anesthetic injections of the facet joint or its nerve supply . Diagnostic facet joint injections are expected to meet the cardinal features of a diagnostic test ( i.e. , accuracy , safety and reproducibility ) . Accuracy must be compared with a " gold " or criterion st and ard that can confirm presence or absence of a disease . There is , however , no available gold st and ard , such as biopsy , to measure presence or absence of pain . Hence , there is a degree of uncertainty concerning the accuracy of diagnostic facet joint injections . OBJECTIVES To evaluate accuracy , safety and reproducibility of facet or zygapophysial joint injections in diagnosing chronic spinal pain of facet joint origin . STUDY DESIGN A systematic review of the literature for clinical studies on efficacy and utility of facet joint/nerve injections in diagnosing spinal pain from facet joints . METHODS Relevant literature on diagnostic facet injections was identified through data base search es . Excluded were abstract s , review s , book chapters , case reports and studies based on single blocks or blocks without radiologic control . Prospect i ve studies with placebo control , or controlled comparative local anesthetic blocks , were given priority over retrospective studies . Each study was grade d using AHRQ and QUADAS criteria . The level of evidence was classified as conclusive , strong , moderate , limited , or inconclusive . RESULTS Available literature pointed to strong evidence for controlled comparative local anesthetic facet joint medial branch blocks in the diagnosis of neck and low back pain . There was moderate evidence in the diagnosis of pain arising from thoracic facet joints . CONCLUSION The evidence obtained from literature review suggests that controlled comparative local anesthetic blocks of facet joint nerves ( medial branch or dorsal ramus ) are reproducible , reasonably accurate , and safe . The sensitivity , specificity , false-positive rates , and predictive values of these diagnostic tests for neck and low back pain have been vali date d and reproduced in multiple studies Background While one in ten Australians suffer from chronic low back pain this condition remains extremely difficult to treat . Many contemporary treatments are of unknown value . One potentially useful therapy is the use of motor control exercise . This therapy has a biologically plausible effect , is readily available in primary care and it is of modest cost . However , to date , the efficacy of motor control exercise has not been established . Methods This paper describes the protocol for a clinical trial comparing the effects of motor control exercise versus placebo in the treatment of chronic non-specific low back pain . One hundred and fifty-four participants will be r and omly allocated to receive an 8-week program of motor control exercise or placebo ( detuned short wave and detuned ultrasound ) . Measures of outcomes will be obtained at follow-up appointments at 2 , 6 and 12 months after r and omisation . The primary outcomes are : pain , global perceived effect and patient-generated measure of disability at 2 months and recurrence at 12 months . Discussion This trial will be the first placebo-controlled trial of motor control exercise . The results will inform best practice for treating chronic low back pain and prevent its occurrence Differences in disease prevalence , clinical manifestations , and health outcomes exist between men and women . Sources for this variation range from biological differentiation at the cellular level to behavioral differences influenced by societal gender norms . Typically , biologically based differences between men and women are called sex differences , whereas gender differences describe health differences related , at least in part , to societal constructs of gender ( 13 ) . For example , biological events unique to women , such as pregnancy and menopause , are probably associated with sex differences in occurrence of certain conditions or in response to some medical therapies ( 48 ) . Gender differences probably exist in health-related perceptions and behaviors for women and men with medical conditions that are prevalent for both sexes ( for example , heart disease and chronic pain ) ( 9 –16 ) . Although sex and gender differences are theoretically distinct , they remain difficult to disentangle when differences between men and women in health outcomes and treatment effectiveness are being examined . For this reason , and for brevity , we hereafter refer to sex and gender differences collectively as sex effects . In the past 2 decades , recognition of the importance of sex effects for health outcomes and treatment heterogeneity has been growing . Beginning in 1993 , the National Institutes of Health has issued policies requiring the inclusion of women and minorities in all clinical research and trial design s with valid analysis of sex effects or differences between racial and ethnic groups ( 17 , 18 ) . Since then , the inclusion of women in clinical trials has increased ( 19 , 20 ) , and sex effects have been identified for medications , such as nicotine replacement therapy , analgesics , and aspirin ( 13 , 14 , 21 ) . Recently , sex effects in adverse reactions led to sex-specific dosage recommendations for a widely used sedative ( 7 ) . Despite this progress , representation of women in clinical studies remains inadequate for many conditions ( 22 ) . Further , published clinical trials infrequently report sex effects or discuss the appropriateness of sex-specific analyses ( 19 , 20 , 23 ) . To advance the clinical evidence base and improve health outcomes for women , clinical research must include adequate numbers of women , appropriately conduct sex-specific analyses , and consistently report sex effects . Systematic review s ( SRs ) are a key source of information for clinicians , research ers , and guideline panels . By synthesizing the overall body of evidence for key clinical and research questions , SRs could potentially make a unique contribution to the evaluation of sex effects . To our knowledge , however , the reporting of sex effects by SRs has not been previously examined . Here , we use evidence mapping to systematic ally evaluate the reporting of sex effects by SRs examining a diverse set of interventions for chronic conditions common to women ( that is , depression , diabetes , and chronic pain ) . Evidence mapping is an emerging approach that describes key characteristics of studies for a broad area of medicine ( 2426 ) . Our evidence map addresses the volume and characteristics of eligible SRs , including the representation of women in primary studies , whether and how review s reported sex effects , and findings about sex effects . Methods This work was part of a larger report for the Veterans Health Administration ( VHA ) Evidence -based Synthesis Program ( ESP ) . The complete technical report is available online ( www.hsrd . research .va.gov/publications/esp ) and includes additional information on our methods . We focused on SRs to determine the reporting of sex effects , provide high-level information about the volume of current clinical evidence , and summarize information about actual sex effects . Prioritization of Conditions for Inclusion We used forced-ranking prioritization ( 27 ) with our VHA stakeholders to determine our conditions of interest . These stakeholders included representatives from the Health Services Research & Development Center for the Study of Healthcare Innovation , Implementation and Policy ; Health Services Research & Development Women 's Health Research Network ; Women 's Health Research in the Office of Research & Development ; Women 's Health Services ; and Mental Health Services . We initially selected 34 conditions ( Appendix Table 1 ) based on disease prevalence in women , disease burden in women , availability and breadth of effective treatments for men or women , and women veterans ' priorities for gender-specific care . Stakeholders ranked this initial set of conditions , discussed the rankings , and reranked conditions that initially received intermediate priority rankings . After 2 rounds of iterative prioritization , the following conditions were selected : depressive disorders , type 2 diabetes mellitus , and chronic pain ( that is , chronic low back pain , fibromyalgia , and chronic knee pain due to osteoarthritis ) . Appendix Table 1 . Conditions Presented to Stakeholders for Prioritization * Data Sources and Search es In collaboration with an expert reference librarian , we search ed PubMed and Cochrane Data base of Systematic Review s to identify eligible SRs published after 1 October 2009 through 31 October 2014 for depression , 13 February 2015 for diabetes , and 27 February 2015 for chronic pain . Search strategies used Medical Subject Headings and free-text terms for the conditions of interest , eligible interventions , and SRs ( Appendix Table 2 ) . We restricted the search to the past 6 years because SRs are typically out date d within 5 years of publication ( 28 ) , and our goal was to describe the current state of the clinical literature . In addition to electronic search ing , we screened published review s of review s for eligible articles . Appendix Table 2 . Search Strategies Study Selection and Quality Assessment Eligible SRs evaluated interventions in several broad categories ( that is , medications , behavioral interventions , supervised exercise , and quality improvement or organizational interventions ) . We also included condition-specific interventions , such as bariatric surgery for diabetes . Review s that evaluated mixed conditions or multiple interventions must have reported results separately for at least 1 eligible condition or intervention . We included review s of interventions in any setting , with any type of active or inactive comparator , and with any duration of follow-up . Detailed inclusion and exclusion criteria are provided in Appendix Table 3 . Appendix Table 3 . Detailed Inclusion and Exclusion Criteria for Review Eligibility Two investigators screened citations for eligibility , and citations that were considered to be relevant by either person were retained for full-text review . Full-text articles were review ed by 2 investigators , and disagreements were resolved through discussion or adjudicated by a third person . Formal assessment of review quality was beyond the scope of this project . However , we noted whether review s originated from organizations known for high- quality review s ( that is , Cochrane Collaboration , Agency for Healthcare Research and Quality Evidence -based Practice Centers , and VHA ESP ) . For review s reporting sex effects , we also assessed industry funding and whether statistical power was considered . Data Abstract ion Data were abstract ed by 1 investigator and review ed by a second person . Disagreements were resolved by discussion or by a third review er . Abstract ed data included the analysis method ( that is , qualitative synthesis , meta- analysis , network meta- analysis , or individual-patient data [ IPD ] meta- analysis ) ; clinical conditions ; interventions ; main outcomes ; number and design of primary studies ( for example , r and omized , controlled trials [ RCTs ] or observational cohorts ) ; proportion of women in the included primary studies ; and if sex effects were part of the study aims , analysis plan , or results . For review s reporting sex effects , we also recorded the number of primary studies used for sex-specific analyses , effect estimates , and the method used ( for example , metaregression , subgroup analysis , or IPD meta- analysis ) . All eligible review s on depressive disorders and chronic pain conditions were fully abstract ed . All diabetes review s of nonpharmacologic interventions were also fully abstract ed . For eligible diabetes medication review s ( n= 120 ) , we applied an additional prioritization procedure before full abstract ion . We prioritized review s that examined multiple classes of medications or evaluated a single class of medications when 6 or fewer eligible review s were identified . For SRs evaluating a single class ( > 6 eligible review s were identified ) , we used additional prioritization criteria ( for example , the most recent review published in a high-impact journal or work done by an organization known for high- quality review s ) . The remaining unselected but eligible review s ( n= 58 ) had a keyword text search for sex effects and were fully abstract ed only when this search yielded positive results ( n= 13 ) . Data Synthesis and Analysis of SRs We grouped eligible review s by intervention category and described the overall volume of clinical literature for interventions addressing each condition of interest . We also determined the number of review s reporting sex effects and summarized these results . Time trends for the proportion of these review s were examined for depression and diabetes . Examination of Primary RCTs for Selected Interventions We anticipated that some interventions for each condition would have few or no eligible SRs that addressed sex effects . Thus , for a subset of interventions for each condition , we evaluated primary RCTs to determine the feasibility of conducting a future review to evaluate sex effects . Specifically , we examined  quality improvement interventions and psychotherapy for depression ; diet , physical activity , and culturally tailored psychoeducation for diabetes ; behavioral interventions for chronic low back pain ; and exercise interventions Background The Mental Health Biomarker Project ( 2010–2014 ) selected commercial biochemistry markers related to monoamine synthesis and metabolism and measures of visual and auditory processing performance . Within a case – control discovery design with exclusion criteria design ed to produce a highly characterised sample , results from 67 independently DSM IV-R-diagnosed cases of schizophrenia and schizoaffective disorder were compared with those from 67 control participants selected from a local hospital , clinic and community catchment area . Participants underwent protocol -based diagnostic-checking , functional-rating , biological sample - collection for thirty c and i date markers and sensory-processing assessment . Results Fifteen biomarkers were identified on ROC analysis . Using these biomarkers , odds ratios , adjusted for a case – control design , indicated that schizophrenia and schizoaffective disorder were highly associated with dichotic listening disorder , delayed visual processing , low visual span , delayed auditory speed of processing , low reverse digit span as a measure of auditory working memory and elevated levels of catecholamines . Other nutritional and biochemical biomarkers were identified as elevated hydroxyl pyrroline-2-one as a marker of oxidative stress , vitamin D , B6 and folate deficits with elevation of serum B12 and free serum copper to zinc ratio . When individual biomarkers were ranked by odds ratio and correlated with clinical severity , five functional domains of visual processing , auditory processing , oxidative stress , catecholamines and nutritional-biochemical variables were formed . When the strengths of their inter-domain relationships were predicted by Lowess ( non-parametric ) regression , predominant bidirectional relationships were found between visual processing and catecholamine domains . At a cellular level , the nutritional-biochemical domain exerted a pervasive influence on the auditory domain as well as on all other domains . Conclusions The findings of this biomarker research point towards a much-required advance in Psychiatry : quantification of some theoretically-underst and able , translationally-informative , treatment-relevant underpinnings of serious mental illness . This evidence reveals schizophrenia and schizoaffective disorder in a somewhat different manner , as a conglomerate of several disorders many of which are not currently being assessed-for or treated in clinical setting s. Currently available remediation techniques for these underlying conditions have potential to reduce treatment-resistance , relapse-prevention , cost burden and social stigma in these conditions . If replicated and vali date d in prospect i ve trials , such findings will improve progress-monitoring and treatment-response for schizophrenia and schizoaffective disorder Background : Prevalence of musculoskeletal pain is high in jobs with high physical work dem and s. An aerobic exercise intervention targeting cardiovascular health was evaluated for its long term side effects on musculoskeletal pain . Objective : The objective was to investigate if aerobic exercise affects level of musculoskeletal pain from baseline to 4- and 12-months follow-up . Methods : One-hundred- and -sixteen cleaners aged 18–65 years were cluster-r and omized . The aerobic exercise group ( n = 57 ) received worksite aerobic exercise ( 30 min twice a week ) and the reference group ( n = 59 ) lectures in health promotion . Strata were formed according to closest manager ( total 11 strata ) ; clusters were set within strata ( total 40 clusters , 20 in each group ) . Musculoskeletal pain data from eight body regions was collected at baseline and after 4- and 12-months follow-up . The participants stated highest pain in the last month on a scale from 0 , stating no pain , up to 10 , stating worst possible pain . A repeated-measure 2 × 2 multi-adjusted mixed-models design was applied to compare the between-groups differences in an intention to treat analysis . Participants were entered as a r and om effect nested in clusters to account for the cluster-based r and omization . Results : Clinical ly significant reductions ( > 30 % , f 2 > 0.25 ) in the aerobic exercise group , compared to the reference group , in pain intensity in neck , shoulders , arms/wrists were found at 12-months follow-up , and a tendency ( p = 0.07 , f 2 = 0.18 ) to an increase for the knees . At 4-months follow-up the only significant between-group change was an increase in hip pain . Conclusions : This study indicates that aerobic exercise  reduces musculoskeletal pain in the upper extremities , but as an unintended side effect may increase pain in the lower extremities . Aerobic exercise interventions among workers st and ing or walking in the majority of the working hours should tailor exercise to only maintain the positive effect on musculoskeletal pain Abstract Objective : to review and up date the evidence for different forms of manual therapy ( MT ) for patients with different stages of non-specific low back pain ( LBP ) . Data sources : MEDLINE , Cochrane-Register-of-Controlled-Trials , PEDro , EMBASE . Method : A systematic review of MT with a literature search covering the period of January 2000 to April 2013 was conducted by two independent review ers according to Cochrane and PRISMA guidelines . A total of 360 studies were evaluated using qualitative criteria . Two stages of LBP were categorized ; combined acute – subacute and chronic . Further sub-classification was made according to MT intervention : MT1 ( manipulation ) ; MT2 ( mobilization and soft-tissue-techniques ) ; and MT3 ( MT1 combined with MT2 ) . In each sub-category , MT could be combined or not with exercise or usual medical care ( UMC ) . Consequently , quantitative evaluation criteria were applied to 56 eligible r and omized controlled trials ( RCTs ) , and hence 23 low-risk of bias RCTs were identified for review . Only studies providing new up date d information ( 11/23 RCTs ) are presented here . Results : Acute – subacute LBP : STRONG- evidence in favour of MT1 when compared to sham for pain , function and health improvements in the short-term ( 1–3 months ) . MODERATE- evidence to support MT1 and MT3 combined with UMC in comparison to UMC alone for pain , function and health improvements in the short-term . Chronic LBP : MODERATE to STRONG- evidence in favour of MT1 in comparison to sham for pain , function and overall-health in the short-term . MODERATE- evidence in favour of MT3 combined with exercise or UMC in comparison to  exercise  and back-school was established for pain , function and quality -of-life in the short and long-term . LIMITED- evidence in favour of MT2 combined with exercise and UMC in comparison to UMC alone for pain and function from short to long-term . LIMITED- evidence of no effect for MT1 with extension-exercise compared to extension-exercise alone for pain in the short to long-term . Conclusion : This systematic review up date s the evidence for MT with exercise or UMC for different stages of LBP and provides recommendations for future studies Depression is significant among patients with arthritis and musculoskeletal illnesses . However , the impact of depression on osteoarthritis has not been extensively studied . This article highlights the close links between these 2 prevalent chronic conditions , and the associated individual and societal burden . Results from a large clinical trial of depressed older patients with arthritis showed that a focused , collaborative depression care intervention not only decreased depression but also improved arthritis-associated outcomes , such as pain severity and arthritis-related limitations in daily activities . Relative to patients given usual care , patients receiving intervention also reported better health status and higher quality of life . Analyses of the depression interventions uncovered a reciprocal interrelation between depression and pain . Higher severity of either depression or pain decreased the benefits of systematic depression treatment and was associated with worse pain and depression outcomes . Current approaches to management of depression and arthritis do not reflect readily-available evidence -based treatment . A pilot study using a combined approach to address both depression and pain problems among elderly patients with depression and osteoarthritis suggested that benefits for depression , pain , and functional outcomes are strengthened by providing both  pain and depression care management . An integrated depression and pain program using evidence d-based pharmacologic and nonpharmacologic treatments is needed to achieve optimal depression and pain outcomes . Currently , a r and omized trial is under way to evaluate effectiveness of a combined pain and depression intervention using pharmacologic and nonpharmacologic therapies . Key intervention components in these 2 innovative and integrated depression and pain programs can guide clinicians to treat both depression and pain with more focus and intensity Background Self-reported knee pain is highly prevalent among adolescents . As much as 50 % of the non-specific knee pain may be attributed to Patellofemoral Pain Syndrome ( PFPS ) . In the short term , exercise therapy appears to have a better effect than patient education consisting of written information and general advice on exercise or compared with placebo treatment . But the long-term effect of exercise therapy compared with patient education is conflicting . The purpose of this study is to examine the short- and long-term effectiveness of patient education compared with patient education and multimodal physiotherapy applied at a very early stage of the condition among adolescents . Methods / Design This study is a single blind pragmatic cluster r and omised controlled trial . Four upper secondary schools have been invited to participate in the study ( approximately 2500 students , aged 15 - 19 years ) . Students are asked to answer an online question naire regarding musculoskeletal pain . The students who report knee pain are contacted by telephone and offered a clinical examination by a rheumatologist . Subjects who fit the inclusion criteria and are diagnosed with PFPS are invited to participate in the study . A minimum of 102 students with PFPS are then cluster-r and omised into two intervention groups based on which school they attend . Both intervention groups receive written information and education . In addition to patient education , one group receives multimodal physiotherapy consisting primarily of neuromuscular training of the muscles around the foot , knee and hip and home exercises . The students with PFPS fill out self-reported question naires at baseline , 3 , 6 , 12 and 24 months after inclusion in the study . The primary outcome measure is perception of recovery measured on a 7-point Likert scale ranging from " completely recovered " to " worse than ever " at 12 months . Discussion This study is design ed to investigate the effectiveness of patient education compared with patient education combined with multimodal physiotherapy . If patient education and multimodal physiotherapy applied at an early stage of Patellofemoral Pain Syndrome proves effective , it may serve as a basis for optimising the clinical pathway for those suffering from the condition , where specific emphasis can be placed on early diagnosis and early treatment . Trial Registration clinical trials.gov reference :
Inflammatory markers were most commonly measured followed by neurotransmitter-related genes and metabolite-detecting genes .
After exercise interventions , changes in biomarkers involved in neurotransmission and inflammation suggest a hypoalgesic exercise effect .
Significant biomarker associations were found with pain intensity , fatigue , depression , anxiety , and quality of life .
Discussion : It remains a question whether biomarkers can be used as objective measures for risk assessment , diagnosis , or evaluation or as surrogate endpoints in chronic pain .
Regardless , the potential translational value of biomarkers in chronic pain is evident .
Background : Chronic pain is highly prevalent .
Current management is challenged by lack of vali date d objective measures like biological markers .
Clinical pain studies employing exercise interventions have evaluated biomarkers ; however , it is unclear how exercise impacts biomarkers involved in pain pathways and whether these markers are associated with relevant pain-related outcomes .
This systematic review evaluates data from clinical studies employing exercise interventions in chronic musculoskeletal nonmalignant pain conditions in which biomarkers in pain pathways were measured .