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Objective This study aimed at exploring the perspectives and experiences of individuals with neck pain by synthesizing all available qualitative studies. Methods A systematic, qualitative meta-summary and meta-synthesis was conducted following the 5-step methodology proposed by Sandelowski and Barroso. A systematic search of 9 electronic databases was conducted in May 2021. Methodological quality was assessed using the Critical Appraisal Skills Programme tool. Results Nine studies were included in the meta-synthesis for a total of 103 participants (73 women). Eleven categories were identified as belonging to 3 main themes: physical (“My neck has gone wrong”); psychological (“I am worried about my recovery”); and social (“Pain limits my life”). In the physical theme, the categories with the highest frequency were symptoms (67%) followed by body perception (44%). The psychological theme frequencies from highest to lowest were psychological consequences (100%), coping strategies (100%), mindset (67%), expectations from health care professionals (44%), and gender influence (22%). In the social theme, frequencies from highest to lowest were social relationships (56%), work, and activities of daily living and physical activity (44%, respectively). Conclusion An individual’s experience with neck pain is a multidimensional phenomenon in which physical, psychological, and social dimensions influence each other. These findings suggested that health care professionals should be aware of recognizing and evaluating all of the individual’s experiences to offer a truly patient-centered care pathway. Impact This qualitative meta-synthesis responded to a call to action to explore perspectives and experiences of individuals with neck pain. These findings can provide crucial guidance for clinicians as they plan and implement evidence-based recommendations for neck pain.

Background Low Back Pain (LBP) is commonly reported as a very frequent disorder in sports, but its prevalence in runners remains unclear. Objectives To determine the prevalence of LBP in a wide sample of Italian runners. Design A cross-sectional online survey. Setting A national survey, according to the CHERRIES and STROBE guidelines, was performed in 2019. Participants 2539 Italian runners. Methods A sample of Italian runners registered with national running associations was recruited. The survey was conducted using an online survey development platform. The questionnaire was self-reported and included 38 questions. Main outcome measures Descriptive statistics and frequencies were used to analyze results. Relationships between demographics, daily habits and running characteristics and the responses given was calculated with Cramer’s V. Only correlation values higher >0.60 were deemed of interest. Results 2539 questionnaires (63.5%) were valid for analysis. In total, 22.6% of runners reported having experienced LBP in the past year. Most participants (77.0%) reporting episodes of LBP believed it was not caused by running. No significant correlations (Cramer’s V Conclusion The prevalence of LBP among Italian runners was 22,57%. LBP was not associated with training, equipment or lifestyle.

To investigate the beliefs, knowledge, attitudes, behavior, and the clinical management procedures of the Italian physical therapists specialized in orthopedic manipulative physical therapy (OMPT) toward running and its correlation with low back pain (LBP).Survey Monkey software was used to administer the survey. The questionnaire was self-reported and included 26 questions. Descriptive statistics were used and related to the effective respondents for each question.One thousand two hundred and eighteen questionnaires (60.9%) were included in the analysis. A considerable cohort of OMPTs working in private practice clinical settings (Widespread knowledge of clinical and theoretical management of LBP in runners-patients has emerged among Italian OMPTs. The OMPTs' academic background agrees with the recent literature and therefore highlights the paucity of studies related to LBP as running-related injuries.

The coronavirus disease 2019 (COVID-19) pandemic has induced worldwide governments to adopt severe rules limiting individual freedom and imposing social distancing (eg, closing school, mandatory quarantine, restricting entertainments)1 in order to prevent the collapse of national health care systems. In addition to the goal of reducing the COVID-19 pandemic, this paradigm shift brings a different allocation of resources within diagnosis-related groups toward high-intensity levels of care (eg, intensive care units) needed for patients suffering of severe COVID-19. Although these measures are necessary in this pandemic, they constitute a barrier for health care professionals who are usually in close contact with patients needing low-intensity care, such as musculoskeletal (MSK) physical therapists.

Objective Objective The purpose of this review, focused on people with nonspecific neck pain (NSNP), was to assess the effectiveness of specific exercises that recruit the deep cervical muscles compared with other types of exercises or interventions and minimal or no treatment. Methods This systematic review with meta-analysis screened 5 databases (MEDLINE, Embase, CINAHL, Physiotherapy Evidence Database, and The Cochrane Library). Randomized controlled trials investigating the effectiveness of this type of exercise on the intensity of pain were included. Data for each included trial were extracted by 2 independent reviewers. The Cochrane Risk of Bias 2.0 tool was adopted to assess the internal validity of the included trials. The overall quality of evidence was layered with the Grading of Recommendations, Assessment, Development and Evaluations system. Results The review identified a total of 2397 records. Sixteen articles were included in the qualitative synthesis, and 9 studies were included in the meta-analysis. The pooled results found moderate- to very low-quality evidence that deep cervical muscle exercise protocols are not superior to other types of active exercises in reducing the intensity of pain in people with NSNP. Studies not included in the meta-analysis suggest that specific exercises induce better effects that are superior to those of nontreatment with clinically relevant results. Conclusion Clinicians can share this information with their patients through shared decision-making to determine a more tailored approach to adopt. Future studies with high methodological quality are necessary to reach firm conclusions. Impact There has been no consensus on exercise type and dosage for the management of NSNP. This study shows that exercises are a useful tool and that the effect of an exercise program that recruits deep cervical muscles seems to be comparable with the effect of other types of active exercises on pain intensity reduction. Lay summary If you have neck pain, exercises designed by a physical therapist can be a useful treatment tool. An exercise program that targets specific deep cervical muscles may be just as good as other types of active exercises to reduce the intensity of pain intensity; you and your therapist can work together to develop a program.

BACKGROUND: Myofascial trigger points (TrP) are diagnosed upon the presence of clinical signs among which hypersensitivity is considered one of the most important. The detection of the pressure pain threshold (PPT) is used to quantify the degree of hypersensitivity. However, there is a lack of normative data about how hypersensitive a TrP is. Therefore, the objective was to quantify the PPT for myofascial TrP in the upper trapezius muscle and its modification after manual or instrumental physical therapy interventions.METHODS: A systematic review and meta-analysis were conducted among three databases (MEDLINE, Cochrane Library, and PEDro). Two independent reviewers conducted the electronic search and assessed the methodological quality of the included studies.RESULTS: Eleven studies with a high-risk bias indicated that the PPT at TrP sites was 105.11 kPa lower (95% CI: -148.93; -61.28) at active TrP sites (Chi-squared = 1.07, df = 1 (p = 0.30), I2 = 7%) compared to the PPT of the upper trapezius muscles of healthy subjects. In addition, the PPT of TrP was also lower than the reference values coming from the pain-free population. Moreover, the PPT increased after both manual and instrumental treatment by 28.36 kPa (95% CI: 10.75; 45.96) and 75.49 kPa (95% CI: 18.02; 132.95), respectively.CONCLUSIONS: The results of the present study show that TrP has a decreased PPT when compared to healthy muscles and that physical therapy may increase the PPT. However, the clinical relevance of this decreased PPT needs to be further elucidated. Further, the high risk of bias in all the retrieved studies undermines the validity of the results.

BackgroundTo develop an Italian version of the Craniofacial Pain Disability Inventory (CFPDI-I) and investigate its psychometric abilities in patients with temporomandibular disorders (TMD).MethodsThe CFPDI was translated following international standards. The psychometric analyses included reliability by internal consistency (Cronbach’s alpha) and test/retest stability (intraclass correlation coefficient, ICC); construct validity was investigated by matching (a priori hypotheses) the CFPDI-I with the Italian Neck Disability Index (NDI-I), a pain intensity numerical rating scale (NRS), the Italian Pain Catastrophising Scale (PCS-I), the Italian Tampa Scale of Kinesiophobia (TSK-I), and the Italian Migraine Disability Assessment Score Questionnaire (MIDAS) (Pearson’s correlation). Alpha was set at 0.05.ResultsTwo hundred and twelve patients with chronic TMD completed the tool. The questionnaire was internally consistent (α = 0.95) and its stability was good (ICCs = 0.91). As hypothesised, validity figures showed CFPDI-I strongly correlated with the NDI-I (r = 0.66,p r = 0.48,p r = 0.37,p r = 0.35,p r = 0.47,p ConclusionsThe cross-culturally adapted version of the Craniofacial Pain and Disability Inventory (CFPDI-I) showed satisfactory psychometric properties that replicate those of the original version and, therefore, can be implemented in the clinical assessment of Italian people affected by TMD.

Aims and objectives To describe contextual factors (CFs) used by nurses to increase placebo and to prevent nocebo effects. Background Placebo effects have been studied in the nursing discipline, but nocebo effects still remain unexplored. Recently, a set of CFs functioning as triggers of placebo/nocebo effects has been described; however, its use in daily care has never been documented to date. Design A national cross-sectional survey, according to the Checklist for Reporting Results of Internet E-Surveys guidelines and STrengthening the Reporting of OBservational Studies in Epidemiology (STROBE), was performed in 2016. Methods A wide sample of Italian nurses belonging to four national associations was involved. A questionnaire based on CFs literature was developed and administered through the SurveyMonkey Software® exploring: (a) CFs definition, (b) beliefs, (c) case-by-case frequency of use, (d) circumstances of application, (e) clinical conditions where participants perceived their potential beneficial effects, (f) ethical implications and (g) communication issues with the patient. Results Out of 1,411 eligible nurses, 455 answered (32.2%) and 425 questionnaires (30.1%) were valid for the analysis. A total of 211 nurses (49.6%) defined the CFs as an intervention with a possible aspecific effect; participants believed in the CFs (2.91; 95%CI 2.88-2.94), using them >2 times/month, mainly in addition to a nursing intervention to optimise clinical outcomes (n = 79; 18.6%). Psychological and physiological therapeutic effects have been perceived mainly in chronic pain (n = 259; 60.9%) and insomnia (n = 243; 57.2%). According to participants, CFs have been reported as ethically acceptable when exerting beneficial psychological effects (n = 148; 34.8%); however, 103 (24.2%) of nurses did not communicate to the patient when CFs were used. Conclusions Nurses are aware of CFs as elements to increase the placebo and prevent the nocebo effects in concomitance with evidence-based nursing interventions. Relevance to clinical practice The CFs valued by nurses and experienced as effective are mainly based upon the internal quality of the nurse and the quality of the relationship between the nurse and the patient. These qualities require a large personal investment; therefore, nurses should be supported in developing these qualities since their nursing graduation.

Recent studies found that fibromyalgia may underly neuropathic conditions affecting the peripheral nervous system. Moreover, clinical observations and preliminary reports suggest the existence of body perceptions distortions (BPD) like "phantom" feelings of swollen hands and feet, similar to those complained by patients with other neuropathic conditions or subjected to experimental procedures affecting the peripheral nervous system.To investigate the prevalence of self-reported BPD in Italian people with fibromyalgia through an online survey administered with the help of the associations of patients distributed nationwide.cross-sectional study.A nationwide sample of 854 patients out of 1173 subjects enrolled was analyzed after the exclusion of comorbidities and incomplete answers. We additionally performed a post-hoc analysis comparing data of patients who entirely fulfilled the Fibromyalgia Research Criteria (FRC) (2011) for epidemiological studies with respect to those only partially responding to the FRC (FM-).Nearly 90% of subjects reported neuropathic pain, symptoms potentially indicative for small-fiber pathology, and at least 1 BPD, while 2 or more BPD was reported in 64.1% of cases. Phantom feelings of "heaviness", "constriction", and "swelling" were the most frequently self-reported perceptual distortions. BPD were significant correlated with symptoms potentially indicative for small-fiber pathology, neuropathic pain, disability, painful sites, and severity of fibromyalgia (0.20τ-b0.33).Our preliminary findings highlighted that the phenomenon of self-reported BPD in patients with fibromyalgia correlated with neuropathic symptoms. If these results will be confirmed in future studies BPD may be potentially considered as part of the clinical picture of fibromyalgia.

Background During COVID-19 pandemic, physiotherapy lecturers faced the challenge of rapidly shifting from face-to-face to online education. This retrospective case-control study aims to compare students’ satisfaction and performances shown in an online course to a control group of students who underwent the same course delivered face-to-face in the previous five years. Methods Between March and April 2020, a class (n = 46) of entry-level physiotherapy students (University of Verona - Italy), trained by an experienced physiotherapist, had 24-hours online lessons. Students exposed to the same course in the previous five academic years (n = 112), delivered with face-to-face conventional lessons, served as a historical control. The course was organized in 3 sequential phases: (1) PowerPoint presentations were uploaded to the University online platform, (2) asynchronous video recorded lectures were provided on the same platform, and (3) between online lectures, the lecturer and students could communicate through an email chat to promote understanding, dispel any doubts and collect requests for supplementary material (e.g., scientific articles, videos, webinars, podcasts). Outcomes were: (1) satisfaction as routinely measured by University with a national instrument and populated in a database; (2) performance as measured with an oral examination. Results We compared satisfaction with the course, expressed on a 5-point Likert scale, resulting in no differences between online and face-to-face teaching (Kruskal-Wallis 2 = 0.24, df = 1, p = 0.62). We weighted up students’ results by comparing their mean performances with the mean performances of the same course delivered face-to-face in the previous five years, founding a statistical significance in favour of online teaching (Wilcoxon rank sum test W = 1665, p < 0.001). Conclusions Online teaching in entry-level Physiotherapy seems to be a feasible option to face COVID-19 pandemic, as satisfies students as well as face-to-face courses and leading to a similar performance. Entry-level Bachelors in Physiotherapy may consider moving to eLearning to facilitate access to higher education. Universities will have to train lecturers to help them develop appropriate pedagogical skills, and supply suitable support in terms of economic, organizational, and technological issues, aimed at guaranteeing a high level of education to their students. Trial registration Retrospectively registered.

Background The sit-to-stand (STS) test is usually included in the clinical assessment of balance and its instrumented analysis may support clinicians in objectively assessing the risk of falling. The aim of the present study was to assess if kinetic parameters of STS collected using a force platform, with particular focus on the raising and stabilization phase, could discriminate between young and older adults. Methods Twenty-four adults (age ranging from 18 to 65 years old) and 28 elderly adults (older than 65 years old) performed STS on a force platform. Data on ground reaction forces, sway, displacement and velocity of the center of pressure were gathered during the raising and the stabilization phases. Results elderly subjects showed significant greater global sway (146.97 vs 119.85; p p p p Conclusions The analysis of STS performed on a force platform provides further information about the age-specific pattern of STS execution. The stabilization phase of STS seems to be the more challenging for functional independent older adults and should be considered during balance assessment. Further studies are needed to confirm findings and improve generalizability of this study.

It is well established that muscle percussion may lead to the excitation of muscle fibres. It is still debated, however, whether the excitation arises directly at the percussion site or reflexively, at the end plates. Here we sampled surface electromyograms (EMGs) from multiple locations along human vastus medialis fibres to address this issue. In five healthy subjects, contractions were elicited by percussing the distal fibre endings at different intensities (5–50 N), and the patellar tendon. EMGs were detected with two 32-electrode arrays, positioned longitudinally and transversally to the percussed fibres, to detect the origin and the propagation of action potentials and their spatial distribution across vastus medialis. During muscle percussion, compound action potentials were first observed at the electrode closest to the tapping site with latency smaller than 5 ms, and spatial extension confined to the percussed strip. Conversely, during tendon tap (and voluntary contractions), action potentials were first detected by electrodes closest to end plates and at a greater latency (mean ± s.d., 28.2 ± 1.7 ms, p

Objective Recent studies have highlighted that about 50% of fibromyalgic patients has a neuropathy of small- and/or large-fibers which could partially explain the puzzling symptoms of fibromyalgia (FM). Our aim was to investigate the estimated prevalence of self-reported neuropathic pain and small-fiber neuropathic symptoms (SFNS) indicative for the presence of small-fiber pathology in FM patients. Methods A nationwide sample of patients was recruited to participate in an on-line survey. Two groups of patients were considered in post-hoc analysis: those positive (FM+) to the Fibromyalgia Research Criteria (FRC) and those complaining typical symptoms of fibromyalgia without fulfilling the FRC (FM−). Results We collected data from 854 patients (749 FM+ and 105 FM−). Patients that scored = 50/100 at the Neuropathic Pain Symptoms Inventory (NPSI), indicating severe neuropathic pain, were 57.3% (62.4% in FM+ and 21.0% in FM−). Around 46% of patients presented three or more SFNS that could be suggestive of small fiber pathology, the most frequent being dry eyes/mouth, allodynia, and dyshidrosis. The NPSI score showed significant moderate/strong associations with disability (Spearman's rho = 0.61), pain (rho = 0.66), stiffness level (rho = 0.46), number of painful sites (rho = 0.40), and SFNS (rho = 0.44). Despite the high prevalence of neuropathic pain and other symptoms attributable to potential small and/or large fibers pathology, neurophysiologic investigations were performed in 43.6% of cases and skin punch biopsy only in 1.9% of patients enrolled, as well as the assumption of anti-neuropathic pain drugs (13.2%). Conclusions Our findings underscore the high estimated prevalence of neuropathic pain and SFNS in FM patients.

Myofascial trigger points (TP) constitute a conundrum in research and clinical practice as their etiopathogenesis is debated. Several studies investigating one or few muscles have shown that both active and latent TP causes an increased muscle activity, however the influence of TP on modular motor control during a reaching task is still unclear. Electromyographic signals, recorded from the muscles of the shoulder girdle and upper arm during a reaching task, were decomposed with Non-Negative Matrix Factorization algorithm. The extracted matrices of motor modules and activation signals were used to label the muscles condition as dominant or non-dominant. The presence of latent and active TP was detected in each muscle with manual examination. Despite a similar muscle activity was observed, we found that muscles with active TP had increased weighting coefficients when labeled in the dominant condition. No influences were found when muscles were in the non-dominant condition. These findings suggest that TP altered the motor control without co-contraction patterns. As a preliminary evidence, the present results suggest that the increased weighting coefficients in presence of TPs are associated with an alteration of the modular motor control without affecting the dimensionality of motor modules for each individual and reciprocal inhibition.

Introduction The physiotherapy approach to musculoskeletal pain is currently pointing more towards a hands-off management of patients by education and exercise therapy. However, hands-on techniques still represent a core element of musculoskeletal physiotherapy practice appreciated by patients and widely taught in educational program and clinical professional development training. Purpose This professional issue explain why hands-on techniques may be considered a specific form of touch and outlines the importance of having a deep and wider understanding of their action mechanisms. Three aspects of the human touch, namely analgesic, affective and somatoperceptual are considered in light of the current literature. Implications The view of hands-on techniques as a specific form of human touch implies a change of perspective. Primarily, manual therapy techniques are based on the physical properties of the delivered stimulus (requiring knowledge of anatomy, biomechanics and neurophysiology) as well as on the emotional properties that emerge from the sympathetic contact established with the patient. Secondarily, the manual therapists should develop relationship and communicative skills allowing this kind of touch to emerge. Thirdly, accordingly with this new perspective, the study of the multifaceted mechanisms of action of hands-on techniques requires a multidisciplinary team of researchers including specialists apparently far from the clinical field. Finally, the recognition of the therapeutic value of touch as one of the most qualifying professional acts of physiotherapists is needed and guarantees patients of its best evidence-based delivering.

Backgrounds: Contextual factors (CFs) have been recently proposed as triggers of placebo and nocebo effects in musculoskeletal pain. CFs encompass the features of the clinician (e.g. uniform), patient (e.g. expectations), patient-clinician relationship (e.g. verbal communication), treatment (e.g. overt therapy), and healthcare setting (e.g. design). To date, the researchers' understanding of Italian patients' knowledge about the role of CFs in musculoskeletal pain is lacking. Objectives: The aim of this study was to investigate attitudes and beliefs of Italian patients with musculoskeletal pain about the use of CFs in clinical practice. Methods: A national sample of Italian patients with musculoskeletal pain was recruited from 12 outpatient private clinics in Italy. An invitation to participate in an online survey was sent to patients: a) exhibiting musculoskeletal pain; b) aged 18-75; c) with a valid e-mail account; and d) understanding Italian language. Survey Monkey software was used to deliver the survey. The questionnaire was self-reported and included 17 questions and 2 clinical vignettes on the patients' behavior, beliefs, and attitudes towards the adoption of CFs in clinical practice. Descriptive statistics and frequencies described the actual number of respondents to each question. Results: One thousand one hundred twelve patients participated in the survey. Five hundred seventy-four participants were female (52%). The average age of patients was 41.7 ± 15.2 years. Patients defined CFs as an intervention with an unspecific effect (64.3%), but they believed in their clinical effectiveness. They identified several therapeutic effects of CFs for different health problems. Their use was considered ethically acceptable when it exerts beneficial psychological effects (60.4%), but it was banned if considered deceptive (51.1%). During clinical practice, patients wanted to be informed about the use of CFs (46.0%) that are accepted as an addition to other interventions to optimize clinical responses (39.3%). Moreover, patients explained the power of CFs through body-mind connections (37.1%). Conclusion: Patients with musculoskeletal pain had positive attitudes towards the use and effectiveness of CFs when associated with evidence-based therapy. They mostly perceived the adoption of CFs in clinical practice as ethical.

Background and aim: In the acute phase of neuropathic pain due to nerve root disorders, the neurodynamic approach proposes the mobilization of the contralateral limb to decrease the pain and increase the range of motion in the affected limb. The aim of this study was to evaluate the effect of the contralateral knee mobilization on the ipsilateral knee extension range of motion in Slump position in healthy adult subjects. Methods: Thirty-eight healthy subjects underwent a placebo, control and experimental manoeuvres that included a passive contralateral knee mobilization into extension. The knee, hip and cervical angles and distance between glabella and femoral condyle achieved in Slump test position were measured with an optoelectronic motion analysis system before and after each manoeuvre. Results: Experimental manoeuvre produced a statistically significant increase of the knee extension ROM when compared to the control (p=.017) and placebo (p=.007) manoeuvres. A significant increase of the hip angle and distance between glabella and femoral condyle was detected after the experimental manoeuvres (p

Background:Fibromyalgia (FM) is the second most frequent disorder in rheumatic patients. Other than widespread pain, fatigue, sleep disturbance and cognitive impairments, patients complain also symptoms of suspected neuropathic origin, like burning pain, thermal sensitive skin, hyperalgesia, pins and needles sensations. Recent studies highlighted the presence of small- fibers pathology (SFP) and/or large-nerve fibers involvement in about 50% of FM patients, which could be the cause of neuropathic pain.Objectives:The aim of the study was to investigate the prevalence of neuropathic pain and symptoms indicative for the presence of SFP in Italian FM patients, studying the association with clinical variables.Methods:An on-line survey was designed according to the Checklist for Reporting Results of Internet E-Surveys guidelines (CHERRIES) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). The on-line Survey Monkey® platform was adopted to collect data. We calculated a-priori minimum number of 800 responders.We administered the survey by involving 7 FM patients’ associations distributed nationwide between July and September 2019. We explored demographic and clinical variables including pain and stiffness intensity, symptoms duration, and counting of painful sites. Neuropathic Pain Symptoms Inventory (NPSI) and Fibromyalgia Impact Questionnaire (FIQ) were administered. To study the presence of symptoms indicative of potential SFP we asked for the presence of 8 signs and symptoms reported in literature as characteristics of SFPs. Two groups of FM patients were considered: those positive (FM+) to the Fibromyalgia Research Criteria (FRC) (Wolfe et al., 2011), and those complaining typical FM symptoms but not fulfilling the FRC (FM-).Results:The survey was correctly completed by 76% of participants (892/1173). A total sample of 854 patients (749 in FM+ and 105 in FM-) was analyzed after the exclusion of subjects with major comorbidities. The mean NPSI score was significantly higher in FM+ (56.3/100) respect to FM- (34.2/100). NPSI score was ≥50/100 in 62.4% of FM+ patients and in 21.0% of FM-. More than 3 symptoms indicative for SFP were found in 51% of FM+ patients and in 15.2% of FM-. Dry eyes/mouth, allodynia and changed pattern of sweating on body were the 3 most frequently reported symptoms. We found statistically significant strong associations (prho=0.53) and pain (rho=0.63), and a moderate correlation with stiffness levels (rho=0.45) and counting of painful sites (rho=0.33). Symptoms indicative for SFP were significantly correlated (prhoConclusion:This findings highlight the importance of neuropathic pain symptoms identification, since we found a high prevalence and a strong correlation with clinical variables in our cohort of FM patients. The assessment of the neuropathic dimension of pain through self-administered questionnaire should be part of the routine clinical practice.References:[1]Wolfe, F., et al., 2011. Fibromyalgia Criteria and Severity Scales for Clinical and Epidemiological Studies: A Modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. The Journal of Rheumatology 38, 1113–1122.Disclosure of Interests: :Antonello Viceconti: None declared, Tommaso Geri: None declared, Simone De Luca: None declared, Filippo Maselli: None declared, Alberto Sulli Grant/research support from: Laboratori Baldacci, Marco Testa: None declared, Giacomo Rossettini: None declared

Contextual Factors (CFs) have been documented to influence nursing interventions and patients' outcomes triggering placebo/nocebo effects. However, given that no studies to date have explored the beliefs and the use of CFs among nursing students, a cross-sectional study was undertaken. Two Italian nursing programmes were involved and a self-administered survey tool was used. A total of 510 students participated. The majority (266; 52.2%) defined CFs as an intervention without a specific effect on the condition being treated, but with a possible nonspecific effect. They reported a substantial level of confidence in CFs and in using them more than twice/week in addition to nursing interventions to optimise clinical outcomes. Physiological and psychological therapeutic effects were mostly reported by participants in treating insomnia (n = 351; 68.8%) and chronic pain (n = 310; 60.8%). The use of CF was considered ethically acceptable when it exerted beneficial psychological effects (n = 188; 36.8%). Participants communicated to patients that a CF is a treatment that can help and will not hurt (n = 128; 25.1%). Students are aware of the value of CFs. Increasing their emphasis in nursing programmes can promote nursing students’ consideration with regards to their use, their underlying mechanisms, their potential effects, as well as their ethical and comunicative implications.

Isometric bite force control, via measures of force accuracy, force steadiness and force proprioception, was assessed in patients with myogenic temporomandibular disorders (TMDs) compared to healthy controls. Twelve people with myogenic TMDs and twelve age- and gender-matched asymptomatic controls performed maximal voluntary contractions (MVC) of unilateral jaw clenching followed by submaximal isometric contractions, with and without visual feedback of force, at 10, 30 50% and 70% MVC. Force performance was assessed with indices of accuracy (mean distance, MD) and precision (standard deviation, SD) and reported as a percentage of the MVC. A mixed-effect model was used to evaluate differences in MVC, MD and SD. The MVC was lower in the TMD group when clenching either ipsilateral or contralateral to the side of greatest pain (p

Background Context effects are well known and were described as integral part of the clinical setting (1). The conscious use of contextual factors (CF) has been recently proposed as an effective modality capable to influence the physiotherapy outcome by facilitation of placebo responses. (2) To date, the knowledge about CF adoption in clinical practice of physical therapists is absent. Objectives The aim of this study was to investigate frequency of use, beliefs and attitudes about contextual factors among Italian physical therapists specialized in manual therapy (OMTs) Methods An invitation to participate in an online survey was sent to 906 OMTs through the database of the Master in Musculoskeletal Rehabilitation (MRDM) of University of Genova by SurveyMonkey Software®. These likely correspond to more than 85% of the whole OMTs population in Italy. A 17 items questionnaire and two clinical scenarios assessed behaviour, beliefs and attitudes of OMTs about CF adoption in clinical practice and data were analysed by descriptive statistic. Results 906 OMTs were invited to participate in the survey and 558 responded (62%). The majority of OMTs uses CF in their practice frequently (52%). They believe that an actual effect of CF can occur in acute pain (57%), chronic pain (78%) and rheumatologic disorders (56%). OMTs consider the use of CF ethically acceptable when it exerts beneficial psychological effects and their effectiveness was shown during clinical experience (31%). They disagree on the adoption of CF when they are based on deception, undermine the trust between OMT and patients, create legal problems or produce side effects (17%). 38% of respondents do not communicate the use of CF to their patients and they adopt CF as addition to other physical therapy interventions with the aim of optimizing clinical responses (20%). Expectation and psychological mechanisms are believed to be the main aspects behind placebo and nocebo effects induced by CF (7%). Conclusions The use of CF is quite common among Italian OMTs and they mostly had positive attitudes towards their use and effectiveness. References Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. Lancet. 2001 Mar 10;357(9258):757–62. Testa M, Rossettini G. Enhance placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes. Man Ther. 2016;24:65–74. Disclosure of Interest None declared

Background Placebo and nocebo represent psycho-neuro-immuno-endocrinological responses commonly encountered in nursing care (1,2). A new paradigm proposed the contextual factors (CF) as mediators and moderators of these responses (3). To date, the knowledge about the awareness of CF and their use in nursing is scant. Objectives The goal of this study was to examine frequency of use, beliefs and attitudes of Italian specialised nurses regarding the contextual factors. Methods In December 2016, through SurveyMonkey Software®, an online survey was conducted by sending a questionnaire to the members of four Italian Nursing Association, grouping nurses specialized in Neuroscience, Medical, Geriatric and Diabetic care. Behaviours, beliefs and attitudes of nurses about the implementation of CF in clinical practice were assessed by a 17 items questionnaire and resulting data were analysed by descriptive statistic. Results Of the 1411 members of the involved Nursing Associations invited to participate to the survey 425 responded (30.1%). An high number of respondent nurses adopts CF often in their practice (42%). They believe that CF can positively influence acute pain (47.5%), chronic pain (61%) and rheumatologic disorders (42%). 34% of responders consider the use of CF, if it can determine beneficial psychological effects, as ethically accep table. 15.5% responders oppose to the adoption of CF when based on deception or if they undermines trust between nurses and patients. A relevant number of nurses (24%) do not communicate the use of CF to their patients and 19% implement CF as addition to other nursing interventions to optimize clinical responses. Nurses explain the power of CF through patient9s expectation and psychological mechanism (11%). Conclusions The Italian specialised nurses use CF quite frequently and believe that their use has the capacity of positively influencing the clinical outcome. Larger surveys are needed to understand the proportion of use of CF by nurses in common clinical practice in Italy. References Miller LR, Miller FG. Understanding placebo effects: Implications for nursing practice. Nurs Outlook. 2015 Sep-Oct;63(5):601–6. Hauser W, Hansen E, Enck P. Nocebo phenomena in medicine: their relevance in everyday clinical practice. Dtsch Arztebl Int. 2012 Jun;109(26):459–65. Palese A, Rossettini G, Testa M. Placebo and nocebo responses in nursing practice: a discussion paper on the role of contextual factors. In revision at Nurs Inq. Disclosure of Interest None declared

OBJECTIVES To characterize the distribution of masseter muscle activity and force control during bilateral jaw clenching tasks in people with chronic nonspecific neck pain, without an associated temporomandibular disorder. METHODS Twelve volunteers with nonspecific neck pain and 12 age-matched and sex-matched healthy individuals participated. Submaximal symmetrical and asymmetrical bilateral jaw clenching was performed with and without visual feedback of force. Force performance was assessed with indices of accuracy (mean distance, offset error) and precision (standard deviation, coefficient of variation of force). High-density, 2-dimensional, surface electromyography (EMG) was recorded to characterize bilateral masseter muscle activity. The EMG root mean square was computed for each location of the electrode grid to form a map of the EMG amplitude distribution, and the location of the center of activity was measured. RESULTS The patient group showed a different distribution of masseter muscle activity compared with pain-free individuals during both symmetrical and asymmetrical bilateral jaw clenching. The position of the center of activity was positioned more cranial (P

Aim: To assess whether patients with persistent neck pain display evidence of altered masticatory muscle behavior during a jaw-clenching task, despite the absence of orofacial pain or temporomandibular disorders. Methods: Ten subjects with persistent, nonspecific neck pain and 10 age- and sex-matched healthy controls participated. Maximal voluntary contractions (MVCs) of unilateral jaw clenching followed by 5-second submaximal contractions at 10%, 30%, 50%, and 70% MVC were recorded by two flexible force transducers positioned between the first molar teeth. Task performance was quantified by mean distance and offset error from the reference target force as error indices, and standard deviation of force was used as an index of force steadiness. Electromyographic (EMG) activity was recorded bilaterally from the masseter muscle with 13 X 5 grids of electrodes and from the anterior temporalis with bipolar electrodes. Normalized EMG root mean square (RMS) was computed for each location of the grid to form a map of the EMG amplitude distribution, and the average normalized RMS was determined for the bipolar acquisition. Between-group differences were analyzed with the Kruskal Wallis analysis of variance. Results: Task performance was similar in patients and controls. However, patients displayed greater masseter EMG activity bilaterally at higher force levels (P < .05). Conclusion: This study has provided novel evidence of altered motor control of the jaw in people with neck pain despite the absence of orofacial pain or temporomandibular disorders.

PURPOSE: The aim of this study was to cross-culturally adapt the Neck Bournemouth Questionnaire in Italian (NBQ-I) and validate its psychometric properties in a sample of subjects with chronic neck pain. METHODS: The NBQ-I was developed according to international standards. The psychometric testing included the content validity, assessed by considering the relevance and comprehensiveness of the items, the structural validity by factor analysis, the construct validity and the responsiveness by mean of hypotheses testing process comparing, respectively, the test scores and the changes scores of the NBQ-I with those of the Neck Pain and Disability Scale, the Numerical Rating Scale for Pain, the EuroQoL 5 Dimension Index and its numerical rating scale. Finally, we tested the reliability by internal consistency (Cronbach's α) and the interpretability by calculating the Minimal Clinical Important Difference (MCID). RESULTS: The NBQ-I had acceptable psychometric characteristics. A total of 96 subjects with chronicneck pain completed the questionnaire's administration. The high relevance and comprehensiveness of the items pointed out acceptable face validity. The construct validity analysis was based on the structural validity, which revealed a two factors structure explaining 69.2 % of variance, and on the hypotheses testing process, which showed a moderate validity. The internal consistency was acceptable (α = 0.89). The responsiveness, assessed with the hypotheses testing process, was moderate. The MCID was 5.5 points. CONCLUSIONS: The validation process revealed acceptable psychometric properties of the NBQ, whose Italian version can be used for research and clinical purposes.

Background Several questionnaires on neck pain are usually assumed to be unidimensional as their raw scores are considered interval measures. However, the assumption of unidimensionality requires the questionnaire data to satisfy certain criteria when tested with modern psychometric approaches, such as Item Response Theory. The Neck Bournemouth Questionnaire (NBQ) has already been cross-culturally adapted and validated in Italian on a population of subjects with chronic neck pain (Geri et al., 2014). We examined this scale by means of Rasch analysis an Item Response Theory model in order to provide a disease-specific questionnaire whose scores can be assumed as interval variables and, consequently, legitimately their change scores as meaningful. Objectives Validation of the Italian NBQ with Rasch analysis. Methods A sample of 161 subjects with chronic neck pain was assessed with the NBQ. The structure of the scale was preliminarily tested with both exploratory and confirmatory factor analyses. Rasch analysis was performed analysing the following features: the goodness of fit of the data to the model, thresholds ordering, unidimensionality, local independence of the items and Differential Item Functioning (DIF) were examined to consider the NBQ an interval scale. Further, the Person Separation Index and the Mean Location of Persons were used, respectively, to assess the internal consistency and the targeting of the scale. Results Both the exploratory and confirmatory factor analyses revealed a two factors structure of the NBQ. Factor 1 (item 1, 2, 3, 6) fitted the model (χ 2 =10.65, df 8, p =0.22) after removal of item 7, which had low communalities on exploratory factor analysis and further showed disordered thresholds (Figure). Item 2 presented a marginal uniform Differential Item Functioning across educational level. The Person Separation Index was 0.80 and the Mean Location of Persons was 0.48 (SD=1.02). Factor 2 (Item 4 and 5) fitted the model (χ 2 =3.86, df 4, p =0.42). The Person Separation Index and the Mean Location of Persons of factor 2 were, respectively, 0.77 and -0.71 (SD=1.57). Conclusions The NBQ is a useful tool for the assessment of patients with chronic neck pain. The NBQ showed a two factors structure, each factor fitted the Rasch model and therefore works as a unidimensional measure. Using the interval scores of the NBQ may provide meaningful change scores to establish the effectiveness of treatments for chronic neck pain in clinical trials. References Geri T, Signori A, Gianola S, Rossettini G, Grenat G, Checchia G, et al. Cross-cultural adaptation and validation of the Neck Bournemouth Questionnaire in the Italian population. Quality of Life Research. 2014. Epub ahead of print 23 September 2014. Disclosure of Interest None declared

The assessment of the individual ability of modulating and coordinating the right and left bite force is poorly investigated. The present study describes a methodology for the assessment of the bilateral control of the biting force and evaluates the test-retest reliability in a sample of 13 healthy subjects. By modulating the intensity and the left/right balance of the biting force, the subject was able to drive a cursor on the screen to “reach and hold” targets, randomly generated within the physiological “range of force” of the subject. The average motor performance was evaluated by the mean cursor-target distance = 13 ± 5%, the Offset Error = 9 ± 5% and the standard deviation of the force vector = 17.7 ± 6.1% (expressed as % of the target). Mean distance and standard deviation indices had acceptable reliability. This technique improves the characterization of the mandibular motor function and it may have a relevant role for the assessment and rehabilitation of the neuromusculoskeletal disorders affecting the orofacial system.

Background Mastication requires a high degree of coordination between jaw and neck muscles. The spino-trigeminal system supports the hypothesis that the presence of pain in one of these two regions could affect the motor behaviour of the other. While experimental evidences showed that patients with temporomandibular disorders display electromyographic alterations of the neck flexor and extensor muscle (Armijo-Olivo and Magee, 2013), alterations of the jaw muscles in patients with neck pain have not been investigated yet. Objectives To investigate precision, accuracy and electromyographic activity of jaw muscles contraction during a unilateral bite task in subjects with neck pain. Methods Ten subjects with chronic neck pain and an age and gender-matched sample of healthy individuals volunteered for this study. The maximal voluntary bite force (MVC) was measured with a flexible force transducer positioned between the first molar teeth and used to set up a biting task requiring the subjects to match 4 targets (10, 30, 50 and 70%MVC) displayed on a computer monitor. Electromyographic (EMG) signals of the masseter and anterior temporalis muscles were recorded bilaterally. The subject9s force performance was measured using error indices from the reference target like the Mean Distance (MD), Offset Error (OE) and the Standard Deviation (SD) of the delivered force. The Root Mean Square (RMS) of the electromyogram was calculated to detect differences in muscular activity. Between-group differences of the force indices (MD, OE, SD) and EMG activity (RMS) were assessed through Kruskal-Wallis test significance level was set to 0.05. Results There were no significant between-group differences in force production for MD (H =0.38, P=0.5), OE (H =1.81, P=0.2) and SD (H =0.26, P=0.6). A significant difference in electromyographic activity was however detected for the masseter muscle (H =7.19, P=0.007, please refer to Figure) but not for temporalis (H =3.82, P=0.05). Conclusions This study demonstrates that patients with neck pain present higher masticatory muscle activity during a unilateral biting task. Our results support the strong functional relationship between temporomandibular and neck regions and invite to consider, also in clinical setting, the possibility that a disorder affecting one region can have consequences on the functionality of the other. In fact, even though the motor output was comparable between groups, subjects with neck pain displayed higher RMS activity of masseter muscle to deliver the same force. References Armijo-Olivo S, Magee D. Cervical musculoskeletal impairments and temporomandibular disorders. J Oral Maxillofac Res. 2013;3:e4. Disclosure of Interest None declared

Background Even if recent evidences suggest the absence of any relationship between body posture and dental occlusion in provoking spine or temporomandibular disorders, 1 electromyographic studies evidenciated a relationship between temporomandibular disorders and neck pain. Since pain disorders often affect the force production and control because of a feedback impairment, the neck pain might cause a deficit in bite force control. To date no studies were conducted to ascertain such a phenomenon. Objectives To investigate the ability to control bite force in subjects with neck pain Methods A sample of 13 subjects affected by chronic neck pain and 13 healthy subjects, age and gender matched, were recruited after informed consent. Two flexible force transducers housed in a soft envelope positioned between the first molars teeth constituted the force measuring device. The values of two Maximal Voluntary Contractions (MVCs) were used to generate 4 targets representing percentages (10, 30, 50 and 70%) of the right and left MVCs. The task required was to reach and hold for 5” the force targets randomly displayed on the monitor, by tuning the force exerted on both sides. The subject9s force performance was measured using error indices from the reference target like the Mean Distance (MD) and Offset Error (OE). Between-group differences of the force errors (MD, OE) were analyzed using a wilcoxon rank sum test with alpha set at 0.05. Results 13 subjects (10 females, 3 males) with neck pain and a matched control group participated in the study. There were no significant between-group differences in force production for both MD and OE. Conclusions The neck pain subjects did not presented any significant difference in bite force control, compared with healty subjects. These results do not support an etiopathogenetic relationship between neck pain and temporomandibular disorders References Rocha CP, Croci CS, Caria PH. Is there relationship between temporomandibular disorders and head and cervical posture? A systematic review. J Oral Rehabil. 2013 Nov;40(11):875-81. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.6029

Background Neck pain is a musculoskeletal disorder causing high societal and economic costs. The comparison of different treatment strategies across several countries using validated outcome measure is vital in the field of neck pain research. As the Neck Bournemouth Questionnaire (NBQ) holds validated versions with acceptable psychometric properties in several languages, we studied the psychometric properties of the questionnaire in the italian population. Objectives Cross-cultural adaptation and validation of the Italian NBQ (NBQ-I). Methods The forward and back translations of the questionnaire produced the pre-final version, which was adopted as the italian version of the questionnaire (NBQ-I) after preliminary testing on the target population and final approval by an expert committee. The questionnaire was administered in two times, being respectively the beginning and the end of a physiotherapy treatment delivered to the patients with neck pain attending the rehabilitation unit of Santa Corona Hospital (Pietra Ligure, IT). The construct validity and responsiveness were computed by means of hypotheses testing regarding the absolute magnitude of correlations of, respectively, the test scores and change score of the NBQ-I using the Neck Pain and Disability Scale (NPDS), the Numerical Rating Scale for pain intensity (PAIN-NRS), the EuroQoL 5 Dimension Index (EQ5D-IND) and its Numerical Rating Scale for quality of life (EQ5D-NRS) as comparators. The mean change score between the two administrations, the Minimal Clinical Important Difference (MCID) and the floor and ceiling effects were the values used to describe the interpretability. Results The NBQ had acceptable psychometric characteristics ([Table 1][1]). 96 subjects with chronic neck pain completed the questionnaire's administration. The results of the hypotheses testing process revealed a moderate-to-high construct validity and a poor responsiveness of the NBQ-I. The change score had mean 9.4 (SD =13.3) and MCID 5.5 points. Floor and ceiling effects were not observed. ![Figure][2] Conclusions The NBQ-I was successfully validated in a sample of subjects with chronic neck pain. The good construct validity was further supported because the correlations of the test scores with the comparator instruments reflected those observed in different languages. Although the responsiveness was poor, the change score to detect a clinical improvement in the subjects was minimal and resembled those observed in similar populations.1 A limit of this study was the absence of the reliability analysis. References 1. Gay RE, Madson TJ, Cieslak KR. Comparison of the neck disability index and the neck bournemouth questionnaire in a sample of patients with chronic uncomplicated neck pain. J Manipulative Physiol Ther 2007;30:259-262. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2339 [1]: #F1 [2]: pending:yes

Background The muscle impairment in Temporomandibular disorders (TMDs)1, frequently observed in patients with different rheumatic diseases, contribute to diminished recruitment and force tuning ability. The quantitative assessment of the motor function is capital in the diagnosis and rehabilitation of TMDs. In this study, we propose an intuitive visual feedback of the bite force that promote the coordination and control of jaw muscles. Objectives Validity and reliability evaluation of a visual feedback system for masticatory muscle assessment Methods The force signals, measured by two customized force transducers positioned between the first molars teeth, became the spatial coordinates of a cursor which moved on a PC monitor according to the subject9s bite force on the right (axis x) and left sensors (axis y). The subject9s force during a maximal monolateral left (Lx, Ly), monolateral right (Rx, Ry) and bilateral (BILx, BILy) clenching outlined the boundaries of the Working Area (WA) (Figure 1). During a trial, the task required was to match the position of the 23 targets randomly displayed within the WA, each target being displayed for 5 s and alternated with 5 s of rest. Each subject performed two sessions of three trials in two consecutive days. Matching errors were measured by Mean Distance (MD), calculated as the mean cursor-target distance, and Offset Error (OE), calculated as the distance between the mean cursor position and the target. For the reliability analysis of MD and OE, we considered the Intraclass Correlation Coefficient (ICC), the Standard Error of Measurement (SEM), and the Limits of Agreement (LOA). The validity of both indices was investigated with a linear regression analysis. A 2-way repeated measures ANOVA with SESSION (2 levels) and TRIAL (3 levels) as factors was done to control for any learning effect. Results The 13 subjects included showed a wide range of WAs, geometrically representing functional aspects like maximal force, and left/right independence in force generation. MD showed a more acceptable reliability (ICC =0.78, 95%CI 0.43-0.93;SEM =26%;LOA = -29%, 23%) instead of OE (ICC=0.66, 95%CI 0.20–0.88; SEM=37%; LOA = -31%, 42%). The correlation between MD and OE was high (r=0.96, p Conclusions This visual feedback system provided a valid and reliable representation of the mandibular motor function to be extended in the evaluation of patients suffering from rheumatic diseases. The use of error indices (MD, OE) may characterize the individual performance during force control tasks of jaw elevator muscles in health and disease. This technique may also provide specific rehabilitation programs for TMDs because the subject9s improvement during the second session was most likely attributable to a learning effect. References Manfredini D, Guarda-Nardini L, Winocur E, et al., Research diagnostic criteria for temporomandibular disorders: a systematic review of axis I epidemiologic findings. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;112:453. Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.2332