Niamh Moloney

Background and Objective: Research in the management of chronic musculoskeletal pain often focuses on negative factors associated with poor outcomes. In contrast, strengths‐based approaches attempt to identify factors associated with positive outcomes, referred to as protective factors. Significant potential value lies in understanding protective factors in chronic musculoskeletal pain to deliver strengths‐based care. This scoping review aimed to identify protective factors associated with lower pain‐related disability or higher physical function in adults with chronic musculoskeletal pain. Databases and Data Treatment: Searches were conducted across five databases: Medline, CINAHL Ultimate, Embase PsycINFO and SPORTDiscus. Research Screener was used for abstract screening. Results: Seventy‐nine articles met inclusion criteria for data extraction. Overall methodological quality was low and most studies were cross‐sectional. A range of psychological, lifestyle, social and physical factors were associated with lower pain‐related disability/higher physical function. Self‐efficacy was the most frequently reported factor. Other psychological factors included psychological resources, coping strategies, psychological health, acceptance, cognitive factors, perceptions of control and motivational factors. Lifestyle factors included health promotion practices, Mediterranean diet, sleep and physical activity. Identified social factors were socioeconomic and interpersonal factors. Physical factors included exercise capacity, walking performance, strength and range of motion. Conclusions: These factors align with the biopsychosocial understanding of pain and offer a balancing point to the prevailing deficits‐based focus. The findings can be used as a unique resource for clinicians, researchers and educators working in the field of chronic musculoskeletal pain and may assist in developing strength‐based approaches to musculoskeletal pain care. Significance Statement: This scoping review maps available evidence on psychological, lifestyle, social and physical factors that have shown an association with lower pain‐related disability or higher physical function. This offers a contrasting yet complementary perspective to the prevailing focus on deficits in the literature and shines light on factors that could underpin a strengths‐based approach for chronic musculoskeletal pain.

Background: The management of low back pain (LBP) is highly variable and patients often receive management that is not recommended and/or miss out on recommended care. Clinician knowledge and behaviours are strongly influenced by entry-level clinical training and are commonly cited as barriers to implementing evidence-based management. Currently there are no internationally recognised curriculum standards for the teaching of LBP content to ensure graduating clinicians have the appropriate knowledge and competencies to assess and manage LBP. We formed an international interdisciplinary working group to develop curriculum content standards for the teaching of LBP in entry-level clinical training programs. Methods: The working group included representatives from 11 countries: 18 academics and clinicians from healthcare professions who deal with the management of LBP (medicine, physiotherapy, chiropractic, osteopathy, pharmacology, and psychology), seven professional organisation representatives (medicine, physiotherapy, chiropractic, spine societies), and one healthcare consumer. A literature review was performed, including database and hand searches of guidelines and accreditation, curricula, and other policy documents, to identify gaps in current LBP teaching and recommended entry-level knowledge and competencies. The steering group (authors) drafted the initial LBP Curriculum Content Standards (LBP-CCS), which were discussed and modified through two review rounds with the working group. Results: Sixty-two documents informed the draft standards. The final LBP-CCS consisted of four broad topics covering the epidemiology, biopsychosocial contributors, assessment, and management of LBP. For each topic, key knowledge and competencies to be achieved by the end of entry-level clinical training were described. Conclusion: We have developed the LBP-CCS in consultation with an interdisciplinary, international working group. These standards can be used to inform or benchmark the content of curricula related to LBP in new or existing entry-level clinical training programs.

Neuropathic cancer pain (NCP) is prevalent affecting up to 58% of those with persistent pain following cancer treatment. Neuropathic pain can develop from malignancy, after neural tissue insult during surgery and/or exposure to radiation or neurotoxic agents used as part of cancer treatment regimens. Pain following cancer treatment is commonly under‐treated and one barrier identified is poor recognition of pain and inadequate assessment. Recognition of the presence of NCP is important to inform pain management, which is challenging to treat and warrants the use of specific treatments to target neuropathic mechanisms. In this review, approaches for screening and classifying NCP are described. These include screening questionnaires and the application of the updated neuropathic pain grading system in a cancer context. The evidence from neuropathic pain related assessments in cancer populations is provided and highlighted under different neuropathic pain grades. Recommendations for assessment in practice are provided.

Pain is one of the most prevalent and long‐term adverse effects described by people who have undergone breast cancer surgery. Non‐helpful perceptions and thoughts about pain may contribute to the transition of acute to persistent pain. Adding educational interventions to the current physical therapy program in this population may help to improve or prevent persistent pain. Pain neuroscience education (PNE) is a type of educational intervention that addresses the experience of pain in a broader sense by explaining pain not only from a biomedical perspective, but also from a psychological and social perspective. A double‐blinded randomized controlled trial (EduCan trial) investigated whether PNE, in addition to a standard physiotherapy program immediately after surgery for breast cancer, was more effective on somatosensory functioning in the short (4 months postoperatively) and long term (18 months postoperatively), than providing a biomedical explanation for pain. Somatosensory functioning was evaluated using a self‐reported questionnaire as well as a comprehensive quantitative sensory testing evaluation. The findings of this study revealed that adding six sessions of PNE to a standard physical therapy program (n = 184) did not result in a significantly different course of somatosensory functioning up to 18 months postoperatively as compared to biomedical pain education. These findings provide an interesting basis for future research into who should receive PNE after surgery for breast cancer (e.g., patient profiling or phenotyping) and how we can tailor it to the individual to increase its effectiveness.

Background: General medical practitioner (GP) recruitment and subsequent data collection in clinical practice are challenging and may limit successful completion of a large-scale trial. The aim of this study was to assess the feasibility of undertaking a cluster randomised controlled trial to test an intervention to reduce non-indicated imaging for low back pain in general medical practice. Methods: A pilot cluster randomised controlled trial was performed, with recruitment of GPs and randomisation of GP clinics. All GPs attended a training session and were asked to record low back pain codes in electronic medical records for any low back pain presentations. Intervention group GPs were trained in the use of a patient education booklet to be used during low back pain patient visits. Control group GPs provided usual care. Outcomes for the proposed trial were collected to determine feasibility. GP recruitment was assessed as the proportion of GPs approached who consented to participate. Low back pain imaging outcomes were collected from electronic medical records (counts of patients presenting with low back pain) and from Australian healthcare administrative (Medicare) data (counts of imaging use). GP compliance with study procedures was assessed and qualitative data reported. Results: Thirty-four GP clinics were approached, with four participating (12%). At these clinics, 13/19 (68%) GPs consented to participate, and 10/19 (53%) started the study. Outcome data were collected from medical records for all GPs. Three GPs (30%) withdrew consent to access Medicare data, limiting reporting of imaging outcome measures. Three GPs (30%) self-reported low compliance entering low back pain codes. Conclusions: This pilot cluster randomised controlled trial demonstrated the feasibility of many aspects of a full-scale effectiveness study, while also identifying a number of challenges that need to be resolved. Recommendations related to GP recruitment, study compliance, data collection, and outcome measures were made to increase the success of a future trial. Trial registration: Australia and New Zealand Clinical Trials Register (ANZCTR), Trial ID: ACTRN12619000991112; Registered 11 July 2019, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376973

Pain is one of the most common and long-lasting side effects reported by women surgically treated for breast cancer. Educational interventions may optimize the current physical therapy modalities for pain prevention or relief in this population. Pain neuroscience education (PNE) is an educational intervention that explains the pain experience not only from a biomedical perspective but also the psychological and social factors that contribute to it. Through a double-blinded randomized controlled trial (EduCan trial) it was investigated if PNE, in addition to the standard physiotherapy program immediately after breast cancer surgery, was more effective over the course of 18 months postoperatively than providing a biomedical explanation for pain. Primary outcome was the change in pain-related disability (Pain Disability Index, 0-70) over 12 months. Secondary outcomes included change in pain intensity, upper limb function, physical activity level, and emotional functioning over 4, 6, 8, 12, and 18 months postoperatively. Multivariate linear models for repeated (longitudinal) measures were used to compare changes. Preoperative and postoperative moderators of the change in pain-related disability were also explored. Of 184 participants randomized, the mean (SD) age in the PNE and biomedical education group was 55.4 (11.5) and 55.2 (11.4) years, respectively. The change in pain-related disability from baseline to 12 months postoperatively did not differ between the 2 groups (PNE 4.22 [95% confidence interval [CI]: 1.40-7.03], biomedical 5.53 [95% CI: 2.74-8.32], difference in change −1.31 [95% CI: −5.28 to 2.65], P = 0.516). Similar results were observed for all secondary outcomes. Future research should explore whether a more patient-tailored intervention would yield better results.

Purpose It is not clear to what extent signs and symptoms other than arm swelling, including pain, altered sensory function, and body perception disturbances, differ between women with measurable and non-measurable breast cancer–related lymphedema (BCRL). A case–control study was performed to compare these signs and symptoms between (1) women with self-reported BCRL with objectively measurable swelling; (2) women with self-reported BCRL without objective confirmation; and (3) a control group with no self-reported BCRL. Methods The three groups were compared for (1) the severity of self-reported signs and symptoms of BCRL, (2) problems in functioning related to BCRL, (3) pain-related outcomes, (4) sensory functions, and (5) body perception. Results All self-reported outcomes related to signs and symptoms of BCRL and problems in functioning were significantly different between the control group and the other two groups with and without measurable self-reported BCRL (p < 0.001–0.003). Except for “skin texture” (p = 0.01), no differences were found between groups. For pain-related outcomes, sensory function, and body perception, significant differences were found for the mechanical detection threshold (p < 0.01) and self-reported disturbances in body perception (p < 0.001) between the self-reported BCRL groups and control group. Conclusions Diverse signs and symptoms related to BCRL, sensory function, and perception were different among women with self-reported BCRL compared to controls. No differences between women with and without measurable self-reported BCRL were found. Implications for Cancer Survivors The presence of self-reported BCRL, with or without measurable swelling, is a first indication for the need of further diagnostic evaluation.

This chapter considers how the future trajectory of EU capital market governance might fit against the scenarios set out in the Commission’s 2017 White Paper on the Future of Europe. It first identifies the significant difficulties in predicting the future shape of EU capital market governance, given the many uncertainties that attend its development and the incomplete nature of the EU’s current flagship project for capital markets, Capital Markets Union. It highlights regulation and supervision as the two main vectors across which capital market governance is likely to develop and identifies the rise of technocracy, in the form of the increasing influence of the European Securities and Markets Authority (ESMA), as the defining characteristic of the recent development of EU capital market governance. Given current political preferences, the importance of technocracy and the recent trajectory of EU capital market governance, it concludes that ‘carrying on’ is most likely to define future developments.