Silvia Di-Bonaventura

Background: Large language models (LLMs) configured as virtual patients may expand structured practice of clinical reasoning in health professions education. Before testing effectiveness, it must be established whether students engage with them and whether the resulting scores are complete, reliable, and related to performance with real patients. Our earlier pilot randomized trial found very low engagement with a less structured LLM-based approach. Objective: This study aimed to assess the feasibility (adherence, acceptability, and data completeness) of a revised, structured LLM-based clinical reasoning laboratory (Laboratorio de Inteligencia Artificial [LIA]) in undergraduate physical therapy education and to explore its measurement properties, including its association with clinical judgment with a real patient assessed with the Lasater Clinical Judgment Rubric (LCJR). Methods: In this single-arm pilot feasibility study, 27 third-year physical therapy students at a Spanish university completed, in 2024-2025, 3 virtual patient cases (lumbar, cervical, and thoracic spine pain) simulated by ChatGPT (GPT-4) over 4 weeks, each twice. ChatGPT scored each attempt from 0 to 4 on the same 10 dimensions of the Lasater Clinical Judgment Rubric (LCJR; 0-40 points) that human assessors applied (1-4 per dimension; 10-40 points) during a real patient encounter. Feasibility outcomes were case completion, data completeness, and satisfaction (0-10). Measurement outcomes were internal consistency and convergent validity (Spearman correlations between model-generated and human LCJR scores). Variability estimates informed the sample size of a future trial. Results: All 27 students were assessed with the LCJR; 22 (81%) completed at least 1 LIA case. Both attempts of the lumbar, cervical, and thoracic cases were completed by 78%, 63%, and 74% of students, respectively. Satisfaction data were available for 15 students (56%; mean 6.0, SD 1.3), and missing secondary data clustered in the third rotation. Internal consistency was excellent for the LCJR (α=.96) and ranged from .43 to .90 for model-generated ratings. Model-generated LIA scores clustered near the maximum (mean 36.0, SD 1.4). Among completers, LIA scores correlated weakly with the LCJR (ρ=0.25, 95% CI –0.20 to 0.61; ρ=0.44, 95% CI 0.05-0.71, when noncompleted attempts were scored as 0). Grade point average correlated almost perfectly with the LCJR (ρ=0.96; n=22); after adjustment for it, the LIA-LCJR association disappeared (partial ρ=–0.10). A future trial would require approximately 39 students per group (80% power, conservative variance). Conclusions: Delivering the LIA within the curriculum was feasible, but clinical judgment ratings generated by ChatGPT did not reflect those of human assessors with a real patient: they clustered near the maximum and showed no convergent validity once noncompletion was separated from performance. LLM-generated ratings should not be used as outcome or assessment measures without validation against human raters. Case calibration, completion tracking, and clarification of the GPA-LCJR relationship are also needed before a definitive trial. Trial Registration: ClinicalTrials.gov NCT06809634 ; https://clinicaltrials.gov/study/NCT06809634

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Background: Chronic pain is a prevalent and disabling condition that affects physical health but also cognitive domains. Executive functions, including inhibitory control, cognitive flexibility, and working memory, essentials for self-regulation, treatment adherence, and coping with symptoms, are particularly compromised. Physiotherapy interventions, traditionally aimed at physical outcomes, may also influence executive functions; however, their impact remains unclear. Objective: This review aimed to synthesize current evidence regarding the effects of physiotherapy-related interventions on executive function in adults with chronic pain. Methods: The review followed the Cochrane Handbook and Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines, and the protocol was registered in PROSPERO (CRD42024611800). A comprehensive search was performed. Randomized controlled trials (RCTs) included adults with chronic pain (≥3 months) whose executive function outcomes were evaluated after physiotherapy-based interventions. Results: Out of 12,391 records, 10 randomized controlled trials were included. Populations primarily had fibromyalgia, chronic low back pain, and chronic musculoskeletal pain. Interventions encompassed transcranial direct current stimulation (tDCS), transcranial magnetic stimulation (rTMS), neurofeedback, structured exercise, and multimodal physical-cognitive-mindfulness training. Intervention durations ranged from one session to 16 weeks. Executive function was assessed with diverse neuropsychological tests. tDCS improved attention, inhibitory control, cognitive flexibility, and working memory. Exercise interventions showed benefits in working memory and inhibitory control. Conclusions: Preliminary evidence suggests that physiotherapy interventions, particularly anodal tDCS and structured exercise, may improve executive functions in individuals with chronic pain. Future trials should incorporate long-term follow-up. Integrating cognitive targets into physiotherapy may enhance the multidimensional management of chronic pain.

Background: Fibromyalgia (FM) is a complex, chronic condition characterized by widespread musculoskeletal pain, cognitive dysfunction, fatigue, and emotional comorbidities such as anxiety and depression. These symptoms severely impact daily functioning and quality of life. Although non-pharmacological strategies—such as therapeutic exercise and patient education—are recommended as first-line treatments, their implementation outside the clinical setting remains a challenge due to low adherence and lack of continuity. Objective: To evaluate the effectiveness of a digital health intervention—BEI app—as a complement to usual care in improving clinical and functional outcomes among patients with fibromyalgia. Methods: This is a randomized controlled trial (RCT) with two parallel arms (1:1 allocation). A total of 70 adult participants with fibromyalgia (diagnosed per ACR 2016 criteria) will be recruited through a patient association in Madrid, Spain. The control group will receive 12 weeks of standard, in-person treatment consisting of group-based education and physical activity. The experimental group will receive the same in- person program plus daily access to the BEI mobile application, which includes educational modules, physical and cognitive training, symptom tracking, and personalized feedback. Outcomes will be assessed at baseline, week 6 (mid- intervention), week 12 (post-intervention), and week 24 (follow-up). Primary outcomes include pain intensity (VAS) and functional impact (FIQR). Secondary outcomes include catastrophizing, self-efficacy, cognitive function, physical activity, anxiety, depression, quality of life, app engagement, and satisfaction. Expected results: The results of this trial will provide evidence regarding the potential of mHealth tools to enhance adherence, self-efficacy, and functional outcomes in individuals with fibromyalgia. Trial registration: NCT07090434 ( ClinicalTrials.gov )

Background: Clinical reasoning is a critical skill for physical therapists, involving the collection and interpretation of patient information to form accurate diagnoses. Traditional training often lacks the diversity of clinical cases necessary for students to develop these skills comprehensively. Large language models (LLMs) like GPT-4 have the potential to simulate a wide range of clinical scenarios, offering a novel approach to enhance clinical reasoning in physical therapy education. Objective: The aim of the study is to explore the main barriers and facilitators that could be encountered in conducting a randomized clinical trial to study the effectiveness of the implementation of LLM models as tools to work on the clinical reasoning of physical therapy students. Methods: This pilot randomized parallel-group study involved 46 third-year physical therapy students at La Salle Centre for Higher University Studies. Participants were randomly assigned to either the experimental group, which received LLM training, or the control group, which followed the usual curriculum. The intervention lasted for 4 weeks, during which the experimental group used LLM to solve weekly clinical cases. Digital competencies, satisfaction, and costs were evaluated to explore the feasibility of this intervention. Results: The recruitment and participation rates were high, but active engagement with the LLM was low, with only 5.75% (5/23) of the experimental group actively using the model. No significant difference in overall satisfaction was found between the groups, and the cost analysis reflected an initial cost of US $1738 for completing the study. Conclusions: While LLMs have the potential to enhance specific digital competencies in physical therapy students, their practical integration into the curriculum faces challenges. Future studies should focus on improving student engagement with LLMs and extending the training period to determine the feasibility of integrating this tool into physical therapy education and maximize benefits.

Background and Objectives: Exercise-induced hypoalgesia (EIH) is a topic of interest in the scientific community. This umbrella review aimed to analyze EIH research and compare it with public dissemination on X. Materials and Methods: We selected relevant EIH reviews that included a healthy population or patients with pain and studied exercise interventions. A systematic literature search was carried out in PubMed, Web of Science, SciELO, PEDro, and Google Scholar, employing the Population, Intervention, Comparison, and Outcome strategy. Data were extracted and summarized, and methodological quality was assessed with the Quality Assessment Scale for Systematic Reviews, and risk of bias with the Risk of Bias in Systematic Reviews tool. The Physical Activity Guidelines Advisor Committee was employed for evidence synthesis. Simultaneously, advanced X website searches gathered EIH-related content for analysis. Information from posts on X was qualitatively analyzed and contrasted with evidence in the literature. Results: We included nine systematic reviews and 17 narrative reviews. Systematic reviews presented high methodological quality. However, half had low risk of bias, while the other half presented high risk of bias. The EIH in healthy participants was controversial for some exercise modalities, such as aerobic exercise, and the influence of psychological variables. Modalities, such as isotonic resistance exercise, showed favorable effects on hypoalgesia. However, in patients with musculoskeletal pain, different exercise modalities did not generate EIH. X analysis unveiled a considerable representation of science-related content, although with prevalent misinterpretations of scientific evidence. Conclusions: EIH has been extensively studied, yet the certainty of evidence remains limited. While some exercise modalities demonstrate hypoalgesic effects in asymptomatic individuals, these effects remain unverified in patients with musculoskeletal pain. Moreover, the analysis of social media content highlights frequent misinterpretations of scientific evidence, particularly conflating hypoalgesia with analgesia. This underscores the need for more precise, evidence-based communication on social media platforms.

Introduction: PNE, focusing on cognitive aspects, aims to change patients’ beliefs about pain. However, it is unclear if these cognitive changes are sufficient to influence other components such as neuroplastic changes. Objective: To assess whether 3-h pain neuroscience education (PNE) can induce changes in brain-derived neurotrophic factor (BDNF) levels and pain intensity in chronic pain patients. Methods: A double-blind randomized clinical trial was conducted with 66 participants aged 18–65 years old (50.86 ± 8.61) with chronic primary musculoskeletal pain divided into two groups: an intervention group receiving 3-h PNE lecture and a control group that received an educational booklet. Primary outcomes included plasma BDNF levels and perceived pain intensity (VAS). Secondary outcomes included anxiety (HADS-A), depression (HADS-D), catastrophizing (PCS), kinesiophobia (TSK), stress (PSS), and knowledge about pain. Measurements were taken in both groups before and after a three-hour intervention. Data were analyzed using paired t-tests and Cohen’s d for effect sizes. Results: The results showed no significant changes in BDNF levels for the PNE lecture group (p = 0.708) or the educational booklet group (p = 0.298). Both groups showed significant reductions in pain intensity (PNE: p < 0.001, d = 0.70; booklet: p = 0.036, d = 0.39). Secondary variables, such as knowledge (PNE: p < 0.001, d = −0.972; booklet: p < 0.001, d = −0.975) and anxiety (PNE: p < 0.001, d = 0.70; booklet: p = 0.035, d = 0.39), also showed significant improvements. Conclusions: PNE did not significantly change BDNF levels but effectively improved pain intensity, pain-related knowledge, and other clinical variables. These findings suggest that while PNE has cognitive benefits, it may not be sufficient to induce immediate neurobiological changes. Further research is needed to explore long-term effects and incorporate additional therapeutic domains.

Background/Objectives: Fibromyalgia syndrome (FMS) is a multifactorial pain syndrome not only characterized by widespread pain as the primary symptom but also accompanied by physical, psychological, and cognitive manifestations. Impairments in conditioned pain modulation (CPM) are common in this population; however, there is significant heterogeneity in the CPM response among women with FMS. The Left/Right Judgment Task (LRJT) is a validated method for studying motor imagery in chronic pain patients. Previous scientific evidence has not yet thoroughly investigated the relationship between CPM alterations and motor imagery processes in FMS patients. The aim of this study was to investigate the relationship between CPM and motor imagery. Methods: This is a secondary analysis of a cross-sectional study. Pain intensity (NPRS), disability (FIQ), mechanical hyperalgesia (PPT), descending pain modulation (CPM), and laterality discrimination (LRJT) were assessed in 30 women diagnosed with FMS. Participants were divided into two groups, responder and non-responder, according to their response to the CPM test. Results: Findings showed that the FMS subgroup of non-responders to CPM, performed worse in motor imagery processes (LRJT). Additionally, older age and higher mechanical hyperalgesia were also associated with poorer functioning of the inhibitory system. Conclusions: Women with FMS who are non-responders to CPM exhibit a reduced ability to perform motor imagery processes. Additionally, the non-responder group shown significant differences, such as older age and greater initial mechanical hyperalgesia compared to the responder group.

Conditioned pain modulation (CPM) and temporal summation (TS) tests can measure the ability to inhibit pain in fibromyalgia syndrome (FMS) patients and its level of pain sensitization, respectively. However, their clinical validity is still unclear. We studied the association between changes in the CPM and TS tests and the clinical improvement of FMS patients who received therapeutic intervention. We systematically searched for FMS randomized clinical trials with data on therapeutic interventions comparing clinical improvement (pain intensity and symptom severity reduction), CPM, and TS changes relative to control interventions. To study the relationship between TS/CPM and clinical measures, we performed a meta-regression analysis to calculate odds ratios. We included nine studies (484 participants). We found no significant changes in TS or CPM by studying all the interventions together. Our findings show that this lack of difference is likely because pharmacological and non-pharmacological interventions resulted in contrary effects. Non-pharmacological interventions, such as non-invasive neuromodulation, showed the largest effects normalizing CPM/TS. Meta-regression was significantly associated with pain reduction and symptom severity improvement with normalization of TS and CPM. We demonstrate an association between clinical improvement and TS/CPM normalization in FMS patients. Thus, the TS and CPM tests could be surrogate biomarkers in FMS management. Recovering defective endogenous pain modulation mechanisms by targeted non-pharmacological interventions may help establish long-term clinical recovery in FMS patients.