Propose and background:
The objective of this study is to explore the Mézières Method (MM) as a comprehensive approach to cultivating body awareness among individuals suffering from low back pain. MM is recognized for fostering bodily self-awareness and is considered an embodiment practice.
Methods:
For this qualitative phenomenological study, we purposefully selected twenty participants who had sought treatment for low back pain and underwent ten sessions of MM intervention. We conducted semi-structured interviews to delve into their experiences with low back pain and MM treatment. Open-ended questions were designed to encourage participants to share their self-experience, particularly during sessions four, eight, and ten.
Data analysis encompassed several stages: 1. manual transcription, 2. meaning formulation, 3. theme categorization and clustering, 4. exhaustive description of the phenomenon, 5. identification of fundamental structures, and 6. validation of the exhaustive description and its fundamental structure through participant feedback. Atlas.t software was employed for data analysis.
Results:
The results of our analysis revealed two primary categories:
Teaching and Learning Process: This category encompassed subcategories such as embodied learning, the use of physiotherapist tools, and the role of the physiotherapist as a facilitator of body control.
Embodied Awareness: Within this category, subcategories emerged, including integral body awareness, voluntary control, balance, economy, comfort, and pain relief.
Participants perceived MM treatment as an educational process that unfolds in a unique setting. Here, the individual with low back pain engages in embodied learning that integrates the entire body. The physiotherapist is viewed as a mediator of this learning process, utilizing various instruments for teaching and paying close attention to the patient's body control. Pedagogical tools employed by physiotherapists in MM include hand contact, breathing awareness, and exercise. Hand contact is particularly valuable for assessing myofascial tension, as the therapist continually identifies unnecessary tension in different muscle groups.
The core aspect of the MM learning experience is embodied awareness. This concept is expressed through voluntary body control and self-use, involving a comprehensive self-perception that connects all bodily components. The goal is to attain balance, reduce energy consumption, experience comfort, and achieve relief from pain.
The synthesis of these two categories underscores 'embodied learning' as a central element of this study. Embodied learning centers on the bodily interactions between the therapist and the LBP patient, constituting a teaching-learning process. The therapist employs pedagogical tools to facilitate the client's self-discovery, primarily by opening the sensory body to diminish sensory-motor amnesia, achieve body control, and employ the body in more balanced and efficient ways. The ultimate aim is to self-manage pain, either through its prevention or control.
Conclusion: the Mézières Method serves as a strategy that fosters body awareness in individuals with low back pain, enabling them to better utilize their self-knowledge for improved well-being.
Background: Musculoskeletal disorders (MSKDs) demonstrate a high global prevalence and an enormous social and financial burden on healthcare systems worldwide. Exercise therapy has become an established therapeutic approach in the treatment of MSKDs, as it has been shown to improve pain in patients with musculoskeletal complaints. However, the physiological mechanisms underlying these effects of exercise (central and peripheral pain modulation mechanisms) have not yet been conclusively investigated. Purpose: to review the literature regarding the effects of exercise in patients with musculoskeletal pain on modifying: (1) pain-related endogenous substances concentrations (2) changes in cerebral activity of areas linked with pain processing and modulation, and (3) changes in cerebral plasticity of areas linked with pain processing and modulation. Methods: Systematic searches were conducted in five bibliographic databases: Medline, Embase, CINAHL, Cochrane Trials database, and SCOPUS. Randomized control trials ( parallel and crossover), controlled trials, and before-after studies were included if they investigated pain-associated changes at the cerebral level or endogenous substances in adults with MSKDs. Two independent investigators screened, extracted the data, assessed the risk of bias of the included studies, and evaluated the certainty of the evidence of the included studies. The quality of the studies was assessed using risk of bias tools. The overall certainty of the evidence was determined using the GRADE approach. Results: Nineteen studies (in twenty manuscripts) were included. Fourteen studies presenting a high risk of bias, and only four a moderate risk of bias. The studies comprised a total of eight different musculoskeletal pain conditions, various exercise modalities from different categories (e.g., aerobic exercise, body-mind exercise, resistance exercise) and several neurophysiological outcomes (e.g., corticomotor/corticospinal excitability, inhibition and facilitation; fMRI changes in grey matter volume). Changes in brain plasticity were considered in six studies mostly comprising pain-related brain areas in the prefrontal cortex, descending analgesic system, motor cortex pathways, cingulate cortex, and further parts of the limbic system. Changes in the concentration of pain-related endogenous substances was examined in eleven studies. A total of fifteen different substances was investigated, for which in comparison before and after treatment but also compared with to other interventions, placebo or no therapy. Exercise was shown to induce changes on brain activity and several of the pain-related endogenous substances which could correlate with pain relief in various musculoskeletal conditions. Conclusions: These findings provide evidence that exercise induces changes in pain-related brain plasticity, activity, and endogenous substances that may act to relieve pain in individuals with musculoskeletal pain. In search for new, more effective therapeutic methods to treat MSKDs, exercise therapy, which is often still used primarily under conservative structural paradigms, is showing potential to be better utilized and developed under a new neurophysiological approach for pain management. Implications: This systematic review shows a wide range of available evidence on very different effects of exercise on the brain and endogenous substances in terms of pain. Nevertheless, further studies of higher quality are needed to consolidate these results and to advance the transfer of findings into the practical treatment of patients with MSK
Background: Impaired sleep due to low back pain (LBP) might be influenced by multidimensional domains related to the painful experience, although this has been little explored.
Purpose: This study investigated the association between pain-related characteristics with impaired sleep due to LBP in patients with chronic LBP.
Methods: A cross-sectional study from a primary-care based project database from a low-income setting. Data from adults with chronic LBP with information from the 18th item of the Roland and Morris Disability Questionnaire (RMDQ) was included to detect reports of impaired sleep due to LBP. Multidimensional factors related to the pain experience (pain intensity, pain duration, fear of movement and self-efficacy for pain) were evaluated to explore their association with impaired sleep due to LBP.
Results: The final analyses included 301 participants who met the eligibility criteria. In total, 57.1% of patients reported impaired sleep due to LBP. Multivariate logistic regression analyses revealed that higher pain intensity and higher fear of movement were associated with impairment in sleep due to LBP in this population after adjusting for age, self-report of depression, gender and body max index. Impaired sleep due to LBP was not associated with self-efficacy for pain management or pain duration.
Conclusions: Impaired sleep due to LBP was related to more than one pain-related domain in patients with chronic LBP. Thus not only pain intensity but fear of movement should be addressed as an important component of the assessment and management of those with chronic LBP and impaired sleep due to LBP at Primary Care.
Implications: Patients with impaired sleep due to low back pain are those who have higher pain intensity and higher fear of movement. These findings suggest that the multidimensionality of the experience of low back pain needs attention in the assessment and treatment of sleep impairment.
CKGROUND:
Manual pressure techniques on the suboccipital muscles are commonly used physical therapy modalities for people with tension-type headaches, migraine and cervicogenic headaches. Despite its effectiveness, the working mechanisms remain unclear. As the applied pressure is slightly painful, a central ‘pain-inhibits-pain’ mechanism termed Conditioned Pain Modulation (CPM) could be involved. Since CPM is a central mechanism, manual pressure techniques should reduce pain sensitivity on both local and remote test sites. Consequently, we hypothesized that the CPM effect induced by manual pressure techniques is not significantly different from the CPM effect induced by the Cold Pressor test and that both stimuli induce a larger CPM effect than sham techniques.
PURPOSE:
This study aimed to test the role of conditioned pain modulation as central inhibiting pain mechanism underlying manual pressure techniques in the cervical spine.
METHODS:
The effects of three conditioning stimuli on pain sensitivity were measured using pressure pain thresholds (PPT) in three muscles (locally: suboccipital muscles, regionally: trapezius muscle and remotely on the tibialis anterior muscle). The manual pressure techniques (suboccipital), CPT (with the contralateral hand submerged in ice water), and sham techniques (suboccipital) were used as conditioning stimuli. All participants underwent all three conditioning stimuli in random order. The PPT assessors were blinded. Statistical analysis were performed using Linear Mixed Models.
RESULTS:
We included 63 healthy participants. No significant absolute differences were found between manual pressure techniques and CPT on PPT at all test sites (suboccipital muscles, 11 kPa [95%CI:-3 to 25], trapezius muscle, 15 kPa [95%CI: -10 to 39], tibialis anterior muscle, -24 kPa [95%CI:-55 to 7]). Furthermore, manual pressure techniques demonstrated significant differences compared to sham techniques in suboccipital (20 kPa [95%CI:6 to 34]) and trapezius (38 kPa [95%CI:14 to 63]), but not at the tibialis anterior muscle (18 kPa [95%CI:-14 to 49]).
CONCLUSION:
Manual pressure techniques reduce pain sensitivity in the same order as the CPT does, locally, regionally and remotely, suggesting that CPM as a central working mechanism is involved.
IMPLICATIONS:
Mechanism based classification require a deeper understanding of the mechanism of both the pain and the intervention used. This study revealed an underlying central mechanism of conditioned pain modulation, supporting manual therapists in clinical reasoning. In patients with inhibitory CPM, this technique will theoretically likely benefit the patient.
Background: Chronic pain involves several brain regions associated with sensory and affective pain processing. Whereas chronic nonspecific neck pain is one of the most prevalent musculoskeletal disorders, the precise morphological changes of the brain of patients with chronic nonspecific neck pain are still not fully understood.
Purposes: To investigate morphological changes of the brain (cortical thickness and volume) in patients with chronic nonspecific neck pain and to determine the relationships between such morphological changes and clinical features of neck pain and pressure pain sensitivity.
Methods: A cross-sectional study. Thirty participants with nonspecific neck pain (> 3 months) and 30 healthy controls were recruited into the study. Clinical features included pain intensity, disability and symptoms of anxiety and depression (Hospital Anxiety and Depression Scale, HADS). Pressure pain thresholds (PPTs) were measured at C2-3 and C5-6. Cortical thickness and volume of whole-brain and regions of interest (ROIs) were derived from high resolution T1-weighted images. The ROIs included primary somatosensory cortex (S1), prefrontal cortex (PFC), anterior cingulate cortex (ACC), precuneus and insula. Cluster-wise correction for multiple comparisons was performed using FreeSurfer with false discovery rate (FDR) to estimate group analysis of cortical volume and thickness (cluster-weighted p-value; CWP < 0.05). An independent t-test was used to determine between-group differences in extracted cortical thickness and volume for the ROIs (the adjusted p-value ≤ 0.01). Pearson correlation was used to analyze the relationships between brain morphology and clinical features and PPTs.
Results: There were no differences in demographic characteristics between groups (p > 0.05). Cluster-wise analysis revealed increased cortical thickness in the precuneus, paracentral, postcentral, supramarginal, parietal and occipital regions in patients with neck pain compared to controls. The neck pain group exhibited an increase in cortical volume in the parietal region and a decrease in the PFC, precentral, precuneus, supramarginal, parietal, lingual and temporal regions (CWP<0.05). ROIs analysis revealed that patients with neck pain exhibited increased cortical thickness in the S1, ACC and precuneus and decreased cortical volume in the PFC, S1, ACC and insula compared to controls (ES = 0.66 to 0.72, p≤0.01). A decrease in insula volume was correlated with higher neck disability (r = -0.39, p<0.05). PPTs were negatively correlated with cortical thickness in the S1, ACC, PFC and insula (r = -0.26 to -0.33, p<0.05) and positively correlated with cortical volume in the S1, PFC and insula (r = 0.27 to 0.40, p<0.05).
Conclusion: The study provides evidence for alterations of brain morphology (i.e., thickness and volume) in various regions related to pain processing, emotion and cognition in patients with chronic nonspecific neck pain. Some alterations are associated with neck disability and pressure pain sensitivity. The results suggest cortical reorganization, which may play a significant role in modulating and controlling chronic neck pain.
Implications: Alterations of pain-related regions in patients with chronic nonspecific neck pain can not only enhance our understanding of its underlying mechanism, but also facilitate the diagnosis and effective management of chronic nonspecific neck pain.
Keywords: Neck pain, Neuroimaging, Structural brain
Funding acknowledgement: This research project was supported by Fundamental Fund 2022 and 2023, Chiang Mai University (grant number FRB650031/0162 and FRB660046/0162).
Ethics approval: Ethical approval of this study has been granted by the Faculty of Associated Medical Science, Chiang Mai University (No. AMSEC-63EX-101).
Background
Pregnancy related Pelvic Girdle Pain (PPGP) during pregnancy is common, but little is known about the cause1. Perceived cause is an important aspect of illness perception and drives self-management and health care utilisation2. It is unknown what women who are pregnant of their first child (primiparae) perceive as the cause of PPGP. Illness perceptions come into being largely based upon information that people gather. Hence, healthcare providers’ information on PPGP has an important influence in this process, but the exact mechanism is unclear
Purpose
1) To explore and describe the illness perceptions that primiparae hold towards PPGP and its cause in particular. 2) To describe the influence of the health- and illnessbeliefs of the physio- or manual therapist (PT) and the information that primiparae are provided with by PT’s during a first consultation, on health- and illnessbeliefs of primiparae towards PPGP.
Materials and Methods
Both studies used a mixed-methods design, as follows: 1) Semi-structured interviews were performed in primiparae with and without self-reported PPGP. Thematic analysis was used to identify themes to describe health- and illness perceptions on PPGP. Scores on questionnaires (pain, disability and fear on childbirth) were integrated in the analysis to provide a deeper understanding of the themes. 2) Semi-structured interviews on health- and illnessbeliefs towards PPGP were performed in primiparae before and after they consulted a PT, and audio recordings of these consultations were analyzed. Additionally, semi-structured interviews were performed with the PT’s on their health- and illness beliefs on PPGP. Thematic analysis was used across the datasets to describe the illness perceptions of primiparae and how they were influenced by their physical therapist and the information shared during the first consultation for PPGP.
Results
1) Primiparae perceive PPGP primarily as a biomechanical condition during pregnancy, due to hormonal laxity and softening of the pelvic structures. Primiparae experience similar symptoms, but do not always attribute them to PPGP. The attribution of physical symptoms to PPGP plays an important role in health-care seeking behavior. 2) PT’s confirm pre-existing biomechanical beliefs on hormonal laxity and PPGP and treat primiparae with PPGP accordingly, although many of them advocate a biopsychosocial approach. Primiparae perceive the information and treatment of their pain as comprehensible and reassuring.
Conclusion(s)
The perceived cause of PPGP of both patients and PTs largely centers on biomechanical factors. PTs reinforce these biomechanical beliefs in primiparae with self-perceived PPGP.
Further research is needed to understand why physical and manual therapists stick to conventional biomechanical approaches despite growing evidence for biopsychosocial approaches. It is essential to investigate factors that may drive changes in clinical practice in this context. Additionally, it is essential to investigate if altering the narrative on PPGP can positively impact the perception of patients.
Implications
It is important that physical and manual therapists not only become aware of the perceptions patients hold towards PGPP, but also competent and confident in eliciting and addressing them. Moreover, awareness is needed on the role healthcare providers may play in perpetuating the prevailing biomechanical and hormonal approach of PGPP.
Background
Pregnancy related pelvic girdle pain (PGP) is common during and after pregnancy, it affects almost half of all pregnant women. The risk of recurrent PGP in subsequent pregnancies is high, 85% - 88,5%. The majority of women recover spontaneously within three months after delivery. However, a substantial number of women (30%) still report PGP after this period. The pain is intermittent in nature and is provoked and relieved by specific postures and activities related to vertical or directional loading in weight bearing positions. The pain hinders daily life, influencing daily activities like sitting, standing, walking and lifting. It disrupts sleep and often leads to high levels of sick leave. It is therefore important to know which intervention reduces these complaints and improves quality of life.
Purpose:
The aim of the study is to perform a systematic review and perform a meta-analysis on the effect of exercise and additional manual therapy compared to any form of intervention on pain, disability, pelvic floor- function (PFF) and Transverse Abdominal muscle function (mTAF) in women with peripartum pregnancy-related PGP.
Methods
An extensive literature search was conducted using the following electronic databases: MEDLINE, Pubmed, Embase, Emcare, PeDRO, Web of Science, Cochrane, CENTRAL and PsycINFO, from commencement until April 2023. Protocol registry (https://www.clinicaltrials.gov) was screened for upcoming trials. The following PICO (Population, Intervention, Comparison and Outcome) strategy was used; P = Women with pelvic girdle pain peripartum, I = manual therapy, exercise, C other treatment, O = pain, disability, PFF and mTAF. Eligible for inclusion were RCT’s about exercise or manual therapy in women with peripartum PGP written in English.
Results
Only pain and disability could be pooled in six meta-analysis; manual therapy in combination with ‘stabilizing’ exercise compared to other treatment prepartum, ‘stabilizing’ exercise compare to other treatment postpartum and general exercise compared to other treatment prepartum. Preliminary results demonstrated four significant meta- analyses with a low to high heterogeneity (I2 range 0%-88%), due to heterogeneity in definition of PGP, questionnaires and outcome. Prepartum, positive effects of manual therapy combined with ‘stabilizing’ exercise (e.g. mTAF, m. multifidi) were demonstrated on both pain intensity and disability. No effect was found for general exercise (e.g stretching, aerobics, strength training core muscles) interventions compared to other treatment. Postpartum, meta-analyses revealed evidence for positive effects of ‘stabilizing’ exercise on pain intensity and disability when compared to other treatment. It was not possible to pool data for the outcomes PFF, mTAF and quality of life.
Conclusion
Manual therapy in addition to stabilizing exercise as well as stabilizing exercise alone are effective for reducing pain and disability in woman with PGP peripartum. This contradicts the outcomes of other reviews. Due to the heterogeneity among the studies, it’s possible that there is an overestimation in effects.
Implications
To reduce heterogeneity among studies, an international uniform definition of PGP and a uniform core set for physical tests, questionnaires and outcomes is recommended.
Background
Increased diaphragm fatiguability, more pronounced thoracic breathing, and decreased ventilation are often reported in individuals with spinal pain. Given these alterations in respiratory function, beneficial effects of breathing interventions on spinal pain may be presumed. However, their clinical effectiveness remains to be determined.
Purpose
The aim of this systematic review was to provide a comprehensive overview of the literature regarding the effect of breathing interventions on pain and disability in individuals with spinal pain.
Methods
Following the study registration (CRD42020199471), multiple databases were searched until August 2023. Studies investigating the effect of breathing interventions, whether or not compared with a control group, on pain or disability in individuals with spinal pain were eligible for inclusion. Breathing interventions comprised interventions using active instructions to modulate breathing components (e.g. pace, volume) or to increase breathing awareness. The Downs and Black checklist was used to assess risk of bias. Both within- and between-group differences were extracted and synthesized narratively, due to high heterogeneity of both breathing and control interventions.
Results
Fourteen studies related to low back pain (LBP), and six related to neck pain (NP) were included. Seventeen of them received a fair to good quality score (50-85%). Slow deep breathing, respiratory resistance training, and breathing awareness exercises were, amongst others, included as breathing interventions. In the LBP population, breathing interventions significantly decreased pain and disability in respectively 13/13 and 8/10 studies. When compared with an intervention group, pain and disability significantly decreased in respectively 5/12 and 4/11 studies. In the NP population, breathing interventions significantly decreased pain and disability in respectively 6/6 and 3/4 studies. When compared with an intervention group, pain and disability significantly decreased in respectively 4/4 and 1/2 studies.
Conclusion
Although breathing interventions appear to decrease pain and disability in individuals with LBP and NP, it remains unclear whether breathing interventions are more effective than routine physiotherapy or other control treatments for LBP. For NP, preliminary evidence suggests that breathing interventions may be more effective than routine treatment.
Implications
By July 2024, we aim to elucidate which components of the breathing interventions (e.g., breathing rate, volume, resistance) determine their clinical effectiveness in individuals with spinal pain.