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The purpose of this paper was first to gain an in-depth understanding of the barriers and facilitators to implementing the BPS model and pain neuroscience education in the current Lebanese physical therapy health care approach and explore its acceptability. A qualitative semi-structured interview using purposive sampling was conducted with eight Lebanese physical therapists practising in different governorates. The transcribed text from the interviews was analyzed using inductive thematic analysis. Two topics were generated and constructed by the researchers: (1) "barriers to the implementation of pain neuroscience education, with subthemes including (a) "current health care approach," (b) "basic curriculum and continuing education," (c) "patients' barriers"; (2) "facilitators to the implementation of pain neuroscience education," with subthemes containing (a) "interest in the BPS model, (b) "therapeutic alliance," and (c) "motivation for future training on BPS approach." The analysis of the results showed that Lebanese physical therapists currently hold a strong biomedical view of chronic pain, assessment, and treatment. However, despite the presence of barriers and challenges, they are aware and open to consider the implementation and future training about the BPS model and pain neuroscience education in their approach. The exploration of potential barriers and facilitators to the bio-psychosocial model and pain neuroscience education implementation may provide an opportunity for better development and design of a culturally sensitive pain neuroscience education material for Arab-speaking and Lebanese physical therapists. The exploration of barriers and facilitators to the implementation of pain neuroscience education will help to improve pain education and ensure better clinical pain management. The most important barriers were the dominant characteristic of the Lebanese physical therapist's health approach, which is focused on a biomechanically oriented model, and their lack of knowledge to approach chronic pain from a biopsychosocial perspective. [ABSTRACT FROM AUTHOR]

Objective: This systematic review summarizes the relevant literature on the effectiveness of tailored interventions in non‐specific low back pain (NSLBP). Methods: The search strategy has been executed in December 2019 in the electronic databases PubMed, Web of Science and Embase. Study selection, data extraction and quality assessment were done independently by two authors. Results: A total six eligible studies were identified. Five out of six articles used a classification system to subgroup patients. All active patient tailored interventions had similar or better results than the non‐patient tailored interventions, most importantly on pain (short‐ and mid‐term, not for long term follow‐up). Two motor control interventions revealed sustained or increased effects at 12 months follow‐up for disability. For cost‐effectiveness, medication use and work absenteeism, results were inconclusive. Global rating of change evaluation confirmed significant between‐group results at 10 weeks to 4 months follow‐up, but results were not maintained at 12‐month evaluation. Discussion & conclusion: Our findings support the preliminary evidence for the use of patient tailored treatment for reductions in pain and disability. However, our results are of very low to moderate quality evidence and the observed effects strongly depend on the subgroups and the chosen interventions. More high‐quality RCT's with homogenous designs and larger sample sizes are needed. [ABSTRACT FROM AUTHOR]

AbstractPurposeMethodResultsConclusion\nIMPLICATIONS FOR REHABILITATIONThis paper aims to understand the distinctive biopsychosocial aspects and patient perspectives on chronic low back pain in Lebanon, an Arab country with a unique and rich cultural heritage.Qualitative, semi-structured interviews with 12 Lebanese patients purposefully sampled from various governorates. The interviews included participants from different geographic areas and religions. The data underwent analysis through an inductive thematic approach guided by a bounded relativist ontology, a subjectivist epistemology, and a descriptive phenomenological framework. The coding process was managed by computer-assisted qualitative data analysis software (QSR NVivo version 12.0).The researchers identified and constructed two themes: (1) Chronic low back pain: understanding the impact, coping strategies, and communication patterns in lived experiences within the Lebanese context. This theme sheds light on the complexities of pain management and societal influences in Lebanon. (2) Explanatory model of patients living with chronic low back pain in Lebanon. This theme allowed an exploration of the multifaceted narratives of chronic low back pain.This study found that Lebanese individuals attribute chronic low back pain to biomedical factors despite some recognizing psychosocial elements. It emphasizes the need to educate patients on the biopsychosocial model, facilitate better care, and dispel misconceptions.The exploration of patients’ pain perception may provide an opportunity to better develop and design culturally sensitive pain neuroscience education material for Arab-speaking and Lebanese physical therapists.The rehabilitation process should incorporate a balanced biopsychosocial approach, addressing both physical and psychosocial elements of pain, to provide more effective care and outcomes for Lebanese patients who predominantly attribute chronic low back pain to biomedical factors.Lebanese healthcare professionals need to improve communication with Lebanese patients regarding the nature of chronic low back pain, using clear communication to help dispel misconceptions and enhance rehabilitation outcomes.The exploration of patients’ pain perception may provide an opportunity to better develop and design culturally sensitive pain neuroscience education material for Arab-speaking and Lebanese physical therapists.The rehabilitation process should incorporate a balanced biopsychosocial approach, addressing both physical and psychosocial elements of pain, to provide more effective care and outcomes for Lebanese patients who predominantly attribute chronic low back pain to biomedical factors.Lebanese healthcare professionals need to improve communication with Lebanese patients regarding the nature of chronic low back pain, using clear communication to help dispel misconceptions and enhance rehabilitation outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Brain alterations are hypothesized to be present in patients with chronic whiplash‐associated disorders (CWAD). The aim of this case–control study was to examine alterations in cortical thickness and white matter (WM) structure, and the presence of brain microhemorrhages in a patient group encountering chronic neck pain of traumatic origin (i.e., CWAD) when compared with a patient group characterized by nontraumatic chronic neck pain [i.e., chronic idiopathic neck pain (CINP)], and healthy controls. Furthermore, we aimed to investigate associations between brain structure on one hand and cognitive performance and central sensitization (CS) on the other hand. T1‐weighted, diffusion‐weighted and T2*‐weighted magnetic resonance images of the brain were acquired in 105 women (31 controls, 37 CINP, 37 CWAD) to investigate regional cortical thickness, WM structure, and microhemorrhages, respectively. Next, cognitive performance, and CS encompassing distant hyperalgesia and conditioned pain modulation (CPM) efficacy were examined. Cortical thinning in the left precuneus was revealed in CWAD compared with CINP patients. Also, decreased fractional anisotropy, together with increased values of mean diffusivity and radial diffusivity could be observed in the left cingulum hippocampus and tapetum in CWAD compared with CINP, and in the left tapetum in CWAD patients compared with controls. Moreover, the extent of WM structural deficits in the left tapetum coincided with decreased CPM efficacy in the CWAD group. This yields evidence for associations between decreased endogenous pain inhibition, and the degree of regional WM deficits in CWAD. Our results emphasize the role of structural brain alterations in women with CWAD compared with CINP. [ABSTRACT FROM AUTHOR]

Introduction: Prayer is the most common therapy used in alternative medicine1. The objective of this study was to explore the effect of prayers on endogenous pain modulation, pain intensity, and sensitivity in healthy religious participants. Methods: Two hundred and eight healthy religious participants were enrolled in this study and randomly distributed into two groups, a prayer group (n = 156) and a poem reading or control group (n = 52). Participants from the prayer group were allocated to either an active prayer group (n = 94) receiving an active type of praying or to a passive prayer group (n = 62) receiving a passive type of praying. Pain assessments were performed prior to and following the prayer or poem reading interventions and included pressure pain threshold assessment, conditioned pain modulation, and a numerical pain rating scale for perceived pain intensity. Results: A significant group-by-time interaction for PPT (p = 0.014) indicated post-intervention increases in PPT in the prayer group but not in the poem reading control group. Also, a significant group-by-time interaction for PPT (p = 0.005) indicated that these effects were greater in the active prayer group than in the passive prayer group. Participants experienced a decrease in CPM efficacy (p = 0.030) and an increase in pain intensity (p < 0.001) following the interventions, independent of their group allocation. Discussion: The results showed that prayer, irrespective to type, can positively affect pain sensitivity and intensity, but does not influence endogenous pain inhibition. Process evaluation: Future research should focus on understanding the mechanism behind "prayer induced analgesia". [ABSTRACT FROM AUTHOR]

Introduction: The aim of this cross-sectional study is to provide reference values of a conditioned pain modulation (CPM) paradigm using thermal stimulation. Reference values would allow patient phenotyping according to their CPM functional status and can hopefully improve the ability to predict the efficacy of treatments. Methods: Healthy pain-free adults will be recruited. A CPM paradigm using heat thermodes will be applied. The intensity of the test stimulus (TS) will be determined individually based on a NRS score of 4/10. The conditioning stimulus (CS) will be 0.5°C higher than the TS temperature. The CPM effect will be reported both as absolute difference between the NRS scores during and before the CS, as well as the percent change from baseline (1). Influencing factors that will be considered are: age, gender, level of physical activity, chronic stress, intake of oral contraceptives, attentional focus, pain perception and phase of menstrual cycle (2). Results: We expect the average NRS score to decrease after the CS (= positive CPM effect). Discussion: To our knowledge, the present study will be the first one that specifically tries to determine reference values of CPM in pain-free adults using heat for both the TS and CS. However, it is important to note that the reliability and validity of the CPM paradigm used in this study has not been investigated yet. Process evaluation: Subject recruitment has just started and it is clear that successful recruitment will be the most difficult aspect of this study due to the strict inclusion criteria and the current Covid-19 situation. [ABSTRACT FROM AUTHOR]

Introduction: Although physical activity is considered a pillar in the treatment of chronic pain, being physically active poses a challenge for these patients. Patients with low back pain and cancer survivors are not equal in terms of diagnosis, received treatment or life experiences, but both populations are impacted by a high prevalence of persistent pain. With this commonality, it is of interest to compare determinants of physical activity in both populations. Methods: A cross-sectional design is used. Demographic data, condition-specific characteristics, physical activity levels, beliefs on illness and exercise and pain-related emotional factors are collected using questionnaires through an online survey. The aim is to present data on the associations between collected data and physical activity levels within each population and to compare these relationships between both populations. Results: We hypothesize that significant associations will be found between the collected psychosocial factors and self-reported physical activity levels. We hypothesize that the found associations will differ between these two populations. Discussion: The understanding and comparison of the relationship between researched factors and physical activity can lead to more optimal interventions to promote physical activity in these populations. Process evaluation: A difficulty was finding valid and reliable questionnaires on beliefs, barriers and facilitators of exercise which could be applied in both populations. Recruitment of the study will start in December of 2021. [ABSTRACT FROM AUTHOR]

Introduction: Characterizing somatosensory profiles or phenotypes in subgroups of patients may provide indirect insights into underlying pathophysiological mechanisms. The most common method for quantifying somatosensory function is quantitative sensory testing (QST). This paper describes a protocol for determining these somatosensory profiles in a breast cancer population. Methods: A standardized QST protocol is implemented including nine static and dynamic QST methods (mechanical detection-pain thresholds, pressure pain thresholds, thermal detection-pain thresholds for heat and cold, temporal summation and conditioned pain modulation) performed in the surgical area and more distant regions. After the QST assessment, distribution of the data is checked and data is transformed if necessary (raw or log-transformed data).1,2 Subsequently, QST data is z-transformed using the mean and standard deviation of a 15332500, 2022, S2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/papr.13128 by EBSCO SUBSCRIPTION SERVICES - Journal Digital Lic, Wiley Online Library on [19/10/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commonscontrol group as reference data. The algebraic sign of the resulting z score is adjusted appropriately for clarity of data presentation (increased-decreased sensitivity to the tested stimuli). Results: The z-scores acquired with this protocol can inform at a glance whether there is a loss or gain in somatosensory function. Findings can be visualized using a scatter or bar chart. Discussion: Although this protocol was used to determine somatosensory profiles in a breast cancer population, the methodology for determining these profiles can be applied to data from other populations as well. Process evaluation: To correctly interpret QST results, data from a reference population that matches in QST method and test site is required. The proactive development of normative databases for specific QST protocols will improve the efficiency of QST data processing in the future. [ABSTRACT FROM AUTHOR]

Introduction: Numerous scientific studies have established the necessity of a biopsychosocial (BPS) approach in the treatment of chronic pain, however, the implementation into clinical practice falls short. The aim of this study is to investigate the effectiveness of a BPS pain educational program for primary healthcare providers (PHCP) on changes in knowledge and attitude, and the guideline adherence. Methods: Within an implementation project of the Belgian Federal Government, a BPS pain educational program was developed based on recent scientific research, and barriers and facilitators formulated by an expert panel. 300 PHCP from various disciplines followed the course which contains two e-learning sessions and two one-day face-to-face trainings. Changes in knowledge and attitudes regarding chronic pain were measured using the KNowledge and Attitudes of Pain (KNAP). Guideline adherence was measured with two clinical case vignettes. Participants were measured pre-course, post-course and at a 6-month follow-up. The satisfaction of participants regarding the training and implementation into practice was measured during the course and at the follow-up. Results: A shift towards the biopsychosocial perspective that is in line with clinical guidelines is expected after completing the chronic pain course. Discussion: The pain course developed in the present study might increase the biopsychosocial perspective and guideline adherence of PHCP. Process evaluation: The selection of adequate evaluation tools to assess multidisciplinary groups was challenging. Furthermore, it remains to be established whether the improvements observed in knowledge and attitude questionnaires and the guideline adherence based on clinical vignettes reflect actual change in clinical practice. [ABSTRACT FROM AUTHOR]

Introduction: Despite the considerable amount of research performed on conditioned pain modulation (CPM), there are still uncertainties concerning the influence of cognitive mechanisms on CPM efficacy.1 This study aimed to investigate whether the CPM effect is influenced by attention and expectations in healthy adults. Methods: Seventy-two healthy pain-free adults participated in this cross-sectional study undergoing CPM evaluation (i.e. pain pressure threshold (PPT) assessment (= test stimulus (TS)) in response to hot water hand submersion (=conditioning stimulus (CS)) during three experimental protocols administered in randomized order, i.e. (1) a sequential 'neutral' protocol, (2) a 'focus' protocol during which attention was focused on the CS, and (3) a 'distraction' protocol during which attention was directed away from the CS using a distraction task. Participants their pain expectations were recorded before each of the three protocols. Results: Compared to the other protocols, focusing the attention on the CS resulted in smaller CPM magnitudes (p < 0.001), and the distraction protocol resulted in lower NRS ratings for the CS (p < 0.001). A priori expectations accounted for 6.6% of the CPM effect of the neutral protocol (p = 0.035), with expectations of analgesia predicting more efficient CPM. Discussion: It is recommended to rate CS-related pain intensity after CS completion rather than during CS to prevent a reduction of the inhibitory effects by the CPM paradigm. Participants' a priori expectations should be registered as these can influence the induced CPM magnitude. Process evaluation: Building the appropriate statistical models, which took into account confounding factors as well as randomization sequence, was challenging. [ABSTRACT FROM AUTHOR]

Introduction: Chronic Whiplash Associated Disorders (CWAD) are characterized by long-lasting symptoms of neck pain occurring after an acceleration-deceleration injury. Central sensitization (CS) has been suggested as the possible underlying mechanism for these symptoms, and is characterized by changes in the central nervous system. Besides CS, psychological factors are believed to play an important role in the experience of (chronic) pain. Methods: 72 CWAD patients and 55 healthy controls underwent electrical stimuli-based quantitative sensory testing (QST). Detection and pain thresholds (EPT), temporal summation (TS) and conditioned pain modulation (CPM) were examined. Spearman correlations and linear mixed models analyses were performed to assess respectively the hypothesized associations with and group differences in QST. Results: The Pain Catastrophizing magnification subscale correlated with left wrist EPT (r = -0.332; p = 0.004), and the Pain Anxiety Symptom Scale-20 with left wrist (r = -0.325; p = 0.005) and ankle (r = -0.330; p = 0.005) EPT. TS at the ankle correlated with the CS Inventory (r = 0.303; p = 0.010), Short Form 36 pain subscale (r = -0.325; p = 0.005), and Illness Perception Questionnaire revised consequences subscale (r = 0.325; p = 0.005). EPTs of left (p = 0.011) and right wrist (p = 0.023) were lower in the CWAD group, but CPM and TS did not differ between groups. Discussion: QST outcomes relate to psychological constructs, rather than to self-reported pain intensity and distribution. Local hyperalgesia was found in CWAD patients, but no differences in endogenous pain facilitation nor inhibition. Process evaluation: Both CWAD patients reporting unilateral as bilateral neck pain were included, which complicated the interpretation of distal hyperalgesia. [ABSTRACT FROM AUTHOR]

Introduction: Worldwide, breast cancer has the highest incidence rate. Chronic pain during and after cancer treatment is a commonly underdiagnosed and undertreated symptom influencing the patients' quality of life. Generally, breast cancer survivors do not have pain at the time of diagnosis but up to 40% reports to develop chronic pain post-treatment. To improve pain management, biomarkers related to pain chronification would be valuable. Therefore, this study aims to identify susceptibility/risk, nociceptive, prognostic, and diagnostic biomarkers for chronic pain after breast cancer treatment. Methods: A prospective longitudinal study will be performed including 150 breast cancer patients followed from pre-surgery until 12 months post-surgery. At 4 time points, data will be generated through pain assessment, neuroimaging, psychological questionnaires, quantitative sensory testing (QST), and blood analysis. Data will be entered and managed in Research Electronic Data Capture. Multivariable regression analysis will be used to detect candidate biomarkers. Longitudinal changes will be assessed using linear mixed model analyses and correlation analyses will be used to study interrelationships. Results: Based on pain perception in other patient populations, it is hypothesized that neuroimaging, QST, and blood analysis could possibly serve in the different classes of biomarkers whereas psychological factors are expected to fall under prognostic and susceptibility/risk biomarkers. Process evaluation: Necessary contracts are being established. Expected hurdles are patient recruitment and scheduling the data collection. [ABSTRACT FROM AUTHOR]

Introduction: Recent fMRI studies have revealed altered activations in key regions for threat and affective processing of pain in motor imagination tasks. Yet, research in this vein is still lacking in people with chronic whiplash (CWAD). Methods: Sixty CWAD and 32 pain-free participants were included. In the scanner, participants were presented with pictures divided into 3 categories (5 weight bearing, 5 non-weight bearing and 5 neutral pictures) taken from the Pictorial Fear of Activity Scale-Cervical***questionnaire (jittered event-related design). After the scanning, participants were asked to rate each picture in terms of worry, desire to avoidance, anxiety, expected pain. SPM software was used for pre-processing and analysis of the fMRI data. Results: Whole brain analysis revealed greater activation in CWAD for the contrast weight bearing versus neutral pictures in planum temporale/parietal operculum, post/pre-central gyrus, frontal pole, precuneus and posterior cingulate. CWAD have greater activation in precuneus and cerebellum in the non-weight bearing versus neutral contrast. CWAD scored pictures higher than controls, but no correlation between scores and the identified clusters was found. Discussion: The results from this study allow for a better understanding of the maladaptive pain cognitions associated with CWAD by investigating the underlying neural activity alterations. Process evaluation: Several challenges were encountered along the way (data collection and analyses) as this was my first fMRI study. [ABSTRACT FROM AUTHOR]

Introduction: Central sensitization (CS) can lead to muscle motor dysfunction including fatigue via inducing cortical reorganization in specific brain regions in chronic pain populations, such as patients with lateral elbow pain (LEP)1,2. Aim of this study was to investigate the effect of temporal summation, one aspect of CS on the fatigue of the neck muscles that is the most prominent region affected by CS in LEP. To eliminate other factors that may influence fatigue in LEP, healthy participants were included for this study to investigate specifically the effect of TS on fatigue. Methods: Healthy participants were randomly divided into two groups: an experimental (n = 30) and a control (n = 30) group. In the experimental group, pain was induced at the dominant lateral elbow by means of a temporal summation (TS) protocol via applying pressure at the average level of pressure pain thresholds (PPTs) that was assessed twice. Pain intensity was asked to participants at first, fifth and tenth pulse using a Visual Analog Scale. In the control group, a placebo TS protocol was performed by identifying PPTs once. The muscle fatigue of both sternocleidomastoid and upper trapezius muscles was evaluated during a neck flexor/extensor endurance test using surface electromyography. This was performed before and after the intervention. Results: Evoked TS on the lateral elbow may result in neck muscle fatigue. Process evaluation: Participants had a variety of endurance duration that pushed us to determine window interval during EMG analysis. As participants had different kind of interval, we had to make time normalization using Matlab. [ABSTRACT FROM AUTHOR]

Introduction: There is growing acknowledgement of the benefits of incorporating a bio-psychosocial model of understanding pain within physical therapist practice1. Consequently this has led to an increasing interest in interventions such Pain neuroscience education (PNE). However, pain management strategies developed by clinicians in one culture may not necessarily be understood, appropriate, or effective in another culture2 Methods: This study is part of a broader research in the development of culturally sensitive pain neuroscience education for the Lebanese population. Therefore, the purpose of this paper is to first gain an in-depth understanding of the Lebanese physiotherapists' perceptions towards the management of chronic low back pain as well as the knowledge regarding PNE. A qualitative one-to-one semi-structured interviews with 10 practicing physical therapists were conducted. The transcribed text from the interviews was analyzed using inductive thematic analysis. Results: Several themes were generated, identified, and constructed by the researchers: (1) physiotherapists use of a biomechanical approach. (2) Poor knowledge about the bio-psychosocial approach or PNE. (3) Barrier and facilitation for the implementation of PNE. Discussion: The preliminary results showed a limited knowledge of the bio-psychosocial approach, or PNE, and that the Lebanese physical therapist use more a biomechanical approach in the treatment and assessment of people with chronic low back pain. Process evaluation: The results showed that training is needed for physiotherapists to deliver a broader model of care, and that future research should focus on developing a culturally sensitive PNE material. [ABSTRACT FROM AUTHOR]

Introduction: Numerous variables are associated with the physical activity level (PAL) and health-related quality of life (HRQOL) in various populations with chronic pain and fatigue. This study aims to identify transdiagnostic and disease-specific determinants of HRQOL and PAL in two distinct patient groups experiencing chronic pain and fatigue: patients with chronic fatigue syndrome (CFS) and multiple osteochondromas (MO). Methods: Data on sociodemographic, symptomatology, psychosocial variables, HRQOL and the PAL of patients with MO (n = 342) were collected at OLVG Amsterdam through a survey. The same data was collected at Vrije Universiteit Brussel of patients with CFS (n = 103). Determinants of HRQOL and PAL are explored with multiple linear regression models. Results: Preliminary results showed that both groups have a significantly lower HRQOL and PAL (p = 0.001) than the general population. PAL is expected to be positively associated with HRQOL in both groups. Pain and fatigue intensity and depression are hypothesized to be negatively associated with HRQOL and the PAL. The level of catastrophizing is lower in patients with MO; catastrophizing is hypothesized to be negatively associated with the PAL and HRQOL in patients with CFS, but not MO. Discussion: These results are expected to assist research and clinical practice in the development of evidence-based interventions aimed at maximizing HRQOL for patients with CFS and/or MO. Process evaluation: Explanatory variables are not measured with the same measurement instruments in both groups and require recoding. We need to compare associated variables between patient groups, dummy coding for the chronic condition seems the most appropriate procedure. [ABSTRACT FROM AUTHOR]