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• Epigenetics research is making substantial contributions to the elucidation of the intricate underlying mechanisms of chronic diseases and cancer development, allowing remarkable clinical applications and innovative treatments. • Many recent discoveries would suggest that future developments might have applications in rehabilitation. • Epigenetics might offer the exciting possibility of unraveling relevant underlying mechanisms involved in pain conditions and exercise responses, thus allowing researchers and clinicians to fill a gap in their explanatory abilities. • Researchers and clinicians in the field of rehabilitation should be attentive to this rapidly increasing and exciting field and consider combining clinical measures with more biological ones. Epigenetic mechanisms represent a link between the environment and gene function. Recent research shows how early life stress, inflammation, and physical activity can influence gene expression through epigenetic mechanisms. Epigenetic changes—such as DNA methylation and microRNA interference—can be measured in humans and might soon become important biological markers. Epigenetic marks can accompany clinical assessment to measure the effectiveness of various interventions, such as exercise therapy. In addition, epigenetics is improving the understanding of important underlying mechanisms related to the central nervous system, the opioidergic system, and stress responses. Epigenetics is closing a gap in our explanatory abilities and should be implemented to broaden the field of rehabilitation sciences, promote a mechanism-based clinical reasoning, and develop new treatments. In the present review, we focused on epigenetic mechanisms related to pain, psychological factors (such as fear and anxiety), and physical activity, translating relevant findings from these 3 different, yet related, areas of cardinal importance for clinicians. [ABSTRACT FROM AUTHOR]

Objective The objective of this cross-sectional study was to analyze the relationship between symptoms of central sensitization (CS) and important cognitive behavioral and psychosocial factors in a sample of patients with chronic nonspecific low back pain. Methods Participants with chronic nonspecific low back pain for at least 3 months were included in the study. They completed several questionnaires and a functional test. Pearson’s correlation was used to analyze associations between symptoms of CS and pain behavior, functioning, pain, pain catastrophizing, kinesiophobia, and illness perceptions. Additionally, a between-group analysis was performed to compare patients with and without clinically relevant symptoms of CS. Results Data from 38 participants were analyzed. Significant associations were found between symptoms of CS and all other outcomes, especially current pain ( r = 0.510, P = .001), mean pain during the past 7 days ( r = 0.505, P = .001), and pain catastrophizing ( r = 0.518, P = .001). Patients with clinically relevant symptoms of CS scored significantly worse on all outcomes compared with persons without relevant symptoms of CS, except on functioning ( P = .128). Conclusions Symptoms of CS were significantly associated with psychosocial and cognitive behavioral factors. Patients exhibiting a clinically relevant degree of symptoms of CS scored significantly worse on most outcomes, compared with the subgroup of the sample with fewer symptoms of CS. [ABSTRACT FROM AUTHOR]

Study Design A randomized clinical trial. Introduction Rehabilitation treatments for improving fine motor skills (FMS) in hand osteoarthritis (HOA) have not been well explored yet. Purpose of the Study To assess the effectiveness of a rehabilitation program on upper limb disability, independence of activities of daily living (ADLs), fine motor abilities, functional independency, and general self-efficacy in older adults with HOA. Methods About 45 adults (74-86 years) with HOA were assigned to an experimental group for completing an FMS intervention or a control group receiving conventional occupational therapy. Both interventions were performed 3 times/wk, 45 minutes each session, during 8 weeks. Upper limb disability, performance in ADLs, pinch strength, manual dexterity, range of fingers motion, functional independency, and general self-efficacy were assessed at baseline, immediately after treatment, and after 2 months of follow-up. Results FMS group showed significant improvements with a small effect size on manual dexterity ( P ≤ .034; d ≥ 0.48) and a moderate-high effect on range of index ( P ≤ .018; d ≥ 0.58) and thumb ( P ≤ .027; d ≥ 0.39) motion. The control group showed a significant worse range of motion over time in some joints at the index ( P ≤ .037; d ≥ 0.36) finger and thumb ( P ≤ .017; d ≥ 0.55). Conclusions A rehabilitation intervention for FMS may improve manual dexterity and range of fingers motion in HOA, but its effects on upper limb disability, performance in ADLs, pinch strength, functionality, and self-efficacy remain uncertain. Specific interventions of the hand are needed to prevent a worsening in range of finger motion. Level of Evidence 1b. [ABSTRACT FROM AUTHOR]

Objectives: Delayed recovery of muscle function fo'owing exercise has been demonstrated in the lower limbs of patients with multiple sclerosis (MS). However, studies examining this in the upper limbs are currently lacking. This study compared physical activity level (PAL) and recovery of upper limb muscle function following exercise between MS patients and healthy inactive controls. Furthermore, the relationship between PAL and muscle recovery was examined. Methods: PAL of 19 MS patients and 32 controls was measured using an accelerometer for 7 consecutive days. Afterwards, recovery of muscle function was assessed by performing a fatiguing upper limb exercise test with subsequent recovery measures. Results: Muscle recovery of the upper limb muscles was similar in both groups. Average activity counts were significantly lower in MS patients than in the control group. MS patients spent significantly more time being sedentary and less time on activities of moderate intensity compared with the control group. No significant correlation between PAL and recovery of muscle function was found in MS patients. Conclusions: Recovery of upper limb muscle function following exercise is normal in MS patients. MS patients are less physically active than healthy inactive controls. PAL and recovery of upper limb muscle function appear unrelated in MS patients. [ABSTRACT FROM AUTHOR]

Perioperative education should be improved to decrease unfavourable outcomes after lumbar surgery. This trial aimed to compare effectiveness in terms of pain, quality of life, pain cognition, surgical experience, healthcare use, work resumption, and cost-effectiveness of perioperative pain neuroscience education (PPNE) vs traditional biomedical education (perioperative biomedical education [PBE]) in people undergoing surgery for lumbar radiculopathy. In this multicentre RCT (ClinicalTrials.gov: NCT02630732), patients undergoing surgery for lumbar radiculopathy in three Belgian hospitals were randomised to receive PPNE or PBE. Both groups received one preoperative and one postoperative one-to-one education session and a booklet (balanced interventions), with an essentially different content (PPNE: biopsychosocial; PBE: biomedical). Pain was the primary outcome (Visual Analogue Scales+quantitative sensory testing). Assessments were at 3 days, 6 weeks, and 6 and 12 months after surgery. Between March 2016 and April 2020, participants were randomly assigned to PPNE (n =58) or PBE (n =62). At 12 months, PPNE did not lead to significantly better pain outcomes, but it did result in more favourable 36-item Short Form Health Survey physical component (additional increase: 46.94; 95% confidence interval [CI]: 14.16–79.73; medium effect), Tampa Scale of Kinesiophobia (additional decrease: 3.15; 95% CI: 0.25–6.04; small effect), and Pain Catastrophising Scale (additional decrease: 6.18; 95% CI: 1.97–10.39; medium effect) scores. Females of the PPNE group showed higher probability for work resumption (95% vs 60% in the PBE group). PPNE was cost-effective compared with PBE (incremental costs: €–2732; incremental quality-adjusted life years: 0.012). Perioperative pain neuroscience education showed superior clinical and cost-effectiveness than perioperative biomedical education in people undergoing surgery for lumbar radiculopathy. NCT02630732. [ABSTRACT FROM AUTHOR]

• Large trial studying a contemporary neuroscience therapy for chronic whiplash. • Trial integrating stress management in the neuroscience approach for whiplash. • Assess if a contemporary neuroscience therapy can decrease central sensitization. • This trial may provide new improved treatment guidelines for chronic whiplash. • This trial may be used as a basis for recommendations to health authorities. To address the need for a better treatment of chronic whiplash associated disorders (WAD), a contemporary neuroscience approach can be proposed. To examine the effectiveness of a contemporary neuroscience approach, comprising pain neuroscience education, stress management, and cognition-targeted exercise therapy versus conventional physical therapy for reducing disability (primary outcome measure) and improving quality of life and reducing pain, central sensitization, and psychological problems (secondary outcome measures) in people with chronic WAD. The study is a multi-center, two-arm randomized, controlled trial with 1-year follow-up and will be performed in two university-based and one regional hospital. People with chronic WAD (n = 120) will be recruited. The experimental group will receive pain neuroscience education followed by cognition-targeted exercise therapy, and stress management. The control group will receive biomedically focused education followed by graded and active exercise therapy focusing on muscle endurance, strength, and flexibility, and ergonomic principles. The treatment will have a duration of 16 weeks. Functional status (Neck Disability Index) is the primary outcome measure. Secondary outcome measures include quality of life, pain, central sensitization, and psychological and socio-economic factors. In addition, electroencephalography will measure brain activity at rest and during a conditioned pain modulation paradigm. Assessments will take place at baseline, immediately post-treatment and at 6 and 12 months follow-up. This study will examine whether a contemporary neuroscience approach is superior over conventional physical therapy for improving functioning, quality of life, and reducing pain, central sensitization, and psychological problems in people with chronic WAD. [ABSTRACT FROM AUTHOR]

• Explaining pain to patients who survived cancer should be individually tailored. • Take the patient's pain beliefs, cognitions, pain memories, social factors and dominant pain mechanism into account. • Explaining pain implies teaching patients about the underlying biopsychosocial mechanisms of pain. • Pain neuroscience education is a potential solution to improve pain outcome in cancer survivors, but should never be a stand-alone treatment. • Pain neuroscience education should precede interventions such as graded activity, exercise therapy, stress management, sleep management and dietary advice. Pain is one of the most prevalent and debilitating symptom following cancer treatment. This paper entails a practical guide for clinicians willing to apply pain neuroscience education (PNE) in this specific population, or clinical researchers willing to examine the effects of PNE in patients suffering from pain following cancer. Patient-specific information (i.e. beliefs, cognitions, pain memories, social factors) as well as identification of the dominant pain mechanism are needed to tailor the education to the specific needs and beliefs of the patient. Therapists require an in-depth understanding of pain mechanisms, the skills to explain to their patients various pain mechanisms, specific communication skills (e.g. Socratic-style dialogof education) and experience with current evidence-based biopsychosocially-driven pain management strategies for successful implementation of PNE in the clinic. Rather than purely focusing on the biomedical characteristics of pain following cancer (e.g., tissue damage due to past cancer treatment), PNE implies teaching patients about the underlying biopsychosocial mechanisms of pain. Its application is backed-up by mounting evidence supporting the effectiveness of PNE in non-cancer pain populations, and a pilot study in patients having pain following cancer. PNE is a potential solution to improve pain outcome in cancer survivors. Further research using sufficiently powered and well-designed randomized clinical trials should be conducted to examine the potential of PNE in patients having pain following cancer. [ABSTRACT FROM AUTHOR]

Highlights • There is a close interaction between insomnia and pain severity/disability. • CBT-I can improve sleep and pain interference in chronic spinal pain. • Clinical implication 1: combined approach may improve pain, sleep and function. • Clinical implication 2: may lead to new treatment guidelines for professionals. Abstract Background Insomnia is a highly prevalent and debilitating comorbidity that is often not addressed in therapy for chronic spinal pain (CSP). Given the close interaction between insomnia and CSP severity and related disability, targeting sleep problems during therapy could improve treatment outcomes in these patients. Objective Can cognitive behavioral therapy for insomnia (CBT-I) combined with the modern neuroscience approach (i.e. pain neuroscience education and cognition-targeted exercise therapy) reduce pain and improve sleep, physical activity and function in people with CSP and comorbid insomnia? Methods Participants: One-hundred-twenty participants with chronic spinal pain and comorbid insomnia Intervention: CBT-I combined with the modern neuroscience approach (experimental) compared to the modern neuroscience approach alone (control). Both interventions start with three sessions of pain neuroscience education, followed by six sessions of CBT-I and nine sessions of cognition-targeted exercise therapy in the experimental group, or 15 sessions of cognition-targeted exercise therapy in the control group. Measurements Primary outcome measure: self-reported pain severity (Brief Pain Inventory). Secondary outcome measures: pain sensitivity (pressure pain thresholds, and online questionnaires), sleep-related outcomes (home-based polysomnography and online questionnaires), physical activity (actigraphy), and function (online questionnaires). Online questionnaires will be completed at baseline, directly post-treatment, and at 3, 6 and 12 months post-treatment. Polysomnography, pressure pain thresholds and actigraphy will be carried out at baseline, post-treatment and at 12 months follow-up. Discussion Findings may provide (1) a novel therapeutic approach for people with CSP and comorbid insomnia to improve pain, sleep, physical activity and function, and (2) new treatment guidelines for professionals. Trial registration Clinicaltrials.gov NCT03482856 (https://clinicaltrials.gov/ct2/show/NCT03482856). [ABSTRACT FROM AUTHOR]

Background Context: Informing patients about postoperative return to work (RTW) expectations is of utmost importance because of the influence of realistic expectations on RTW outcomes.Purpose: We aimed to give an overview of the duration of sick leave and RTW rates after surgery for lumbar radiculopathy and to list predictors of and factors related to RTW.Study Design: A systematic review was carried out.Methods: A systematic literature search was conducted in PubMed, Web of Science, EMBASE, and SCOPUS. Full-text articles on RTW following surgery for lumbar radiculopathy were included through double-blind screening. Risk of bias was assessed using a modified version of the Downs and Black checklist.Results: Sixty-three full-text articles (total sample size: 7,100 patients) were included. Risk of bias was scored low to high. Mean duration of sick leave ranged from 0.8 to 20 weeks. Within 0.1-240 months post surgery, 3%-100% of patients resumed work. Most important predictors for work resumption were preoperative work status, presence of comorbidities, age, sex and duration of preoperative symptoms. Duration of sick leave can be predicted by the preoperative level of pain or disability and presence of symptoms of depression, occupational mental stress, and lateral disc prolapse. Furthermore, less invasive surgical techniques were found to result in better RTW outcomes compared with more invasive techniques.Conclusions: Diverse results were found for RTW rates and duration of sick leave. Preoperative work status, presence of comorbidities, and several demographic factors were retrieved as predictors of RTW and duration of sick leave. [ABSTRACT FROM AUTHOR]

Background Current treatment for adults with chronic pain often includes Pain Neuroscience Education (PNE) to make people understand the nature underlying their pain and thus provides a clear rational for a biopsychosocial approach. Despite recommendations to use Pain Neuroscience Education as well in children with chronic pain, a specific program, tailored to children aged 6–12 years is lacking. Objectives The aim of this study was to develop a Pain Neuroscience Education program for children with chronic pain and test its feasibility. Methods First the internet and scientific literature was searched for sources (e.g., books, videos, etc.) that might be supportive in teaching children about the neurophysiology of pain. Based on this content, we developed a Pain Neuroscience Education program for children, ‘PNE4Kids’, which was tested for feasibility in three groups of healthy children ( n = 18; 9 girls and 9 boys) aged between 6 and 12 years old. Results and conclusions This paper provides both scientists and clinicians with a specific program to explain the neurophysiology of pain to children with chronic pain, since it is past high time to use a modern neuroscience approach in this vulnerable population. Further research should examine the effectiveness of this developed PNE4Kids program on pain-related outcomes in children with chronic pain. Registration number: NCT02880332 ( https://clinicaltrials.gov/ct2/show/NCT02880332 ). [ABSTRACT FROM AUTHOR]

Background: In the last decade, evidence regarding chronic pain has developed exponentially. Numerous studies show that many chronic pain populations show specific neuroplastic changes in the peripheral and central nervous system. These changes are reflected in clinical manifestations, like a generalized hypersensitivity of the somatosensory system. Besides a hypersensitivity of bottom-up nociceptive transmission, there is also evidence for top-down facilitation of pain due to malfunctioning of the endogenous descending nociceptive modulatory systems. These and other aspects of modern pain neuroscience are starting to be applied within daily clinical practice. However, currently the application of this knowledge is mostly limited to the general adult population with musculoskeletal problems, while evidence is getting stronger that also in other chronic pain populations these neuroplastic processes may contribute to the occurrence and persistence of the pain problem. Therefore, this masterclass article aims at giving an overview of the current modern pain neuroscience knowledge and its potential application in post-cancer, paediatric and sports-related pain problems. [ABSTRACT FROM AUTHOR]

• The amount of moderate-to-vigorous physical activity (MVPA) varies across individuals with nonspecific chronic spinal pain (nCSP) and comorbid insomnia. • Sleep quality, limitations in functioning, body mass index, and fatigue predict MVPA. • No determinants for a change in MVPA after physical therapy were identified. • The change of MVPA in response to physical therapy varied across participants. In healthy people and people with nonspecific chronic spinal pain (nCSP) and/or insomnia, participation in physical activity on a regular basis has several physical and psychological health benefits. However, people with chronic conditions often tend to reduce physical activity participation which can lead to deconditioning over time. Currently, there are no known predictors for an (in)active lifestyle (before and after physical therapy treatment) in people with chronic spinal pain and comorbid insomnia. To examine predictors of pre-treatment moderate-to-vigorous physical activity (MVPA) and to examine determinants for a change in MVPA in response to 14-weeks of active physical therapy treatment in people with nonspecific chronic spinal pain (nCSP) and comorbid insomnia. Baseline data and post-treatment data were analyzed for 66 participants. A linear multiple regression analysis was conducted to examine which factors predict MVPA at baseline. Linear mixed-effects modeling was used to identify determinants for change in MVPA in response to an active physical therapy treatment. Physical fatigue (b = -0.9; 95%CI: -1.59, -0.15), less limitations in functioning as a result of emotional problems (b = 0.1; 95%CI: 0.03, 0.10), mental fatigue (b = -1.0; 95%CI: -1.67, -0.43), lower general sleep quality (b= 0.7; 95%CI: 0.22, 1.17), and body mass index (b = -0.5; 95%CI: -0.93, -0.16) were significant predictors of baseline MVPA. The regression model explained 33.3% of the total variance in baseline MVPA. The change of MVPA in response to the treatment ranged from a decrease of 17.5 to an increase of 16.6 hours per week. No determinants for change in MVPA after treatment could be identified. People with nCSP and comorbid insomnia are more likely to engage in MVPA if they report, at baseline, lower sleep quality, fewer limitations in functioning resulting from emotional problems, lower body mass index, as well as less physical and mental fatigue. [ABSTRACT FROM AUTHOR]

Pain education resources for children using appropriate language and illustrations remain scarce. We aimed to summarize the development process and testing for face and content validity of a structured comic book about pain education for children. A first draft of a comic book was developed (Portuguese and English) based on pain education concepts. Experts in pediatric pain from different countries analyzed content, objectives, language, illustrations, layout, motivation, and cultural adjustment. A third draft developed in Portuguese considering experts' suggestions was presented to children and parents in Brazil. The total adequacy score was calculated from the sum of the scores obtained in each domain, divided by the maximum total score. Descriptive analysis is presented. The expert panel was composed of 11 (64.7%) physical therapists, and 6 (35.3%) psychologists. The total adequacy score (0-100%) was 87.74%. The third draft version of the comic book was presented to 28 children and the final version was presented to 16 children with a mean age of 9.6 years. Children were totally satisfied (n=4; 26.7%) or satisfied (n=9; 56.2%) with the story of the comic book. The readability of the comic book was considered suitable for grades 4 to 6 educational level. The comic book "A Journey to Learn about Pain" was validated for face and content validity by the expert panel and the Brazilian target population. This comic book is available in Portuguese and English and can be a potentially useful resource for children. • Pain is a common problem in the field of pediatrics. • To date, pain education resources for young children are lacking. • A comic book about pain education can be a useful method to present pain concepts to children. • Pain education can contribute to changing children's maladaptive beliefs and behaviors. [ABSTRACT FROM AUTHOR]

• DCM revealed different winning models in healthy participants and back pain patients. • Additional connection between somatosensory cortex and prefrontal cortex in pain patients. • Pain catastrophizing might explain differences in winning models between groups. Despite the worldwide increase in prevalence of chronic pain and the subsequent scientific interest, researchers studying the brain and brain mechanisms in pain patients have not yet clearly identified the exact underlying mechanisms. Quantifying the neuronal interactions in electrophysiological data could help us gain insight into the complexity of chronic pain. Therefore, the aim of this study is to examine how different underlying pain states affect the processing of nociceptive information. Twenty healthy participants, 20 patients with non-neuropathic low back-related leg pain and 20 patients with neuropathic failed back surgery syndrome received nociceptive electrical stimulation at the right sural nerve with simultaneous electroencephalographic recordings. Dynamic Causal Modeling (DCM) was used to infer hidden neuronal states within a Bayesian framework. Pain intensity ratings and stimulus intensity of the nociceptive stimuli did not differ between groups. Compared to healthy participants, both patient groups had the same winning DCM model, with an additional forward and backward connection between the somatosensory cortex and right dorsolateral prefrontal cortex. The additional neuronal connection with the prefrontal cortex as seen in both pain patient groups could be a reflection of the higher attention towards pain in pain patients and might be explained by the higher levels of pain catastrophizing in these patients. In contrast to the similar pain intensity ratings of an acute nociceptive electrical stimulus between pain patients and healthy participants, the brain is processing these stimuli in a different way. [ABSTRACT FROM AUTHOR]