Start looking South: The refugee convention 50 years on

A review essay on books by (1) Efika Feller, Volker Turk, & Frances Nicholson (Eds), Refugee Protection in International Law: UNHCR's Global Consultations on International Protection (Cambridge, UK: Cambridge U Press, 2003); (2) Niklaus Steiner, Mark Gibney & Gil Loescher (Eds), Problems of Protection: The UNHCR, Refugees and Human Rights (New York: Routledge, 2003); & (3) Joanne Van Selm, Khotine Kamanga, John Morrison, Aninia Nadig, Sanja Spoljar-Vrzina, & Loes Van Willigen (Eds), The Refugee Convention at Fifty: A View from Forced Migration Studies (Maryland, Lexington, 2003).

A randomized controlled trial of intensive neurophysiology education in chronic low back pain

Objectives: Cognitive-behavioral pain management programs typically achieve improvements in pain cognitions, disability, and physical performance. However, it is not known whether the neurophysiology education component of such programs contributes to these outcomes. In chronic low back pain patients, we investigated the effect of neurophysiology education on cognitions, disability, and physical performance. Methods: This study was a blinded randomized controlled trial. Individual education sessions on neurophysiology of pain (experimental group) and back anatomy and physiology (control group) were conducted by trained physical therapist educators. Cognitions were evaluated using the Survey of Pain Attitudes (revised) (SOPA(R)), and the Pain Catastrophizing Scale (PCS). Behavioral measures included the Roland Morris Disability Questionnaire (RMDQ), and 3 physical performance tasks; (1) straight leg raise (SLR), (2) forward bending range, and (3) an abdominal drawing-in task, which provides a measure of voluntary activation of the deep abdominal muscles. Methodological checks evaluated non-specific effects of intervention. Results: There was a significant treatment effect on the SOPA(R), PCS, SLR, and forward bending. There was a statistically significant effect on RMDQ; however, the size of this effect was small and probably not clinically meaningful. Discussion: Education about pain neurophysiology changes pain cognitions and physical performance but is insufficient by itself to obtain a change in perceived disability. The results suggest that pain neurophysiology education, but not back school type education, should be included in a wider pain management approach.

Functional capacity evaluation as a performance measure - Evidence for a new approach for clients with chronic back pain

Objectives: To report the research and development of a new approach to Functional Capacity Evaluation, the Gibson Approach to Functional Capacity Evaluation (GAPP FCE) for chronic back pain clients. Methods: Four Studies, including pilot and feasibility testing, expert review, and preliminary interrater reliability examination, are described here. Participants included 7 healthy young adults and 19 rehabilitation clients with back pain who underwent assessment using the GAPP FCE. Thirteen therapists were trained in the approach and were silently observed administering the Functional Capacity Evalutions by at least 1 other trained therapists or the first investigator Or both. An expert review using 5 expert occupational therapists was also conducted. Results: Study 1, the pilot with healthy individuals, indicated that the GAPP FCE was a feasible approach with good utility. Study 2, a pilot using 2 trained therapists assessing 5 back pain clients, supported the clinical feasibility of the approach. The expert review in Study 3 found support for GAPP FCE. Study 4, a trial of the approach with 14 rehabilitation clients, found support for the interrater reliability of recommendations for return to work based on performance in the GAPP FCE. Discussion: The evidence thus far available supports the GAPP FCE as ail approach that provides a Sound method for evaluating the performance of the physical demands of work with clients with chronic back pain. The tool has been shown to have good face and content validity, to meet acceptable test standards, and to have reasonable interrater reliability. Further research is occurring to look at a larger interrater reliability study, to further examine content validity, and to examine predictive validity.

Widespread sensory hypersensitivity is a feature of chronic whiplash-associated disorder but not chronic idiopathic neck pain

Objectives: To investigate sensory changes present in patients with chronic whiplash-associated disorders and chronic idiopathic neck pain using a variety of quantitative sensory tests to better understand the pain processing mechanisms underlying persistent symptoms. Methods: A case control study was used with 29 subjects with chronic whiplash-associated disorders, 20 subjects with chronic idiopathic neck pain, and 20 pain-free volunteers. Pressure pain thresholds were measured over the articular pillars of C2-C3, C5-C6, the median, radial, and ulnar nerve trunks in the arm and over a remote site, the muscle belly of tibialis anterior. Heat pain thresholds, cold pain thresholds, and von Frey hair sensibility were measured over the cervical spine, tibialis anterior, and deltoid insertion. Anxiety was measured with the Short-Form of the Spielberger State Anxiety Inventory. Results: Pressure pain thresholds were decreased over cervical spine sites in both subject groups when compared with controls (P < 0.05). In the chronic whiplash-associated disorders group, pressure pain thresholds were also decreased over the tibialis anterior, median, and radial nerve trunks (P < 0.001). Heat pain thresholds were decreased and cold pain thresholds increased at all sites (P < 0.03). No differences in heat pain thresholds or cold pain thresholds were evident in the idiopathic neck pain group at any site compared with the control group (P > 0.27). No abnormalities in von Frey hair sensibility were evident in either neck pain group (P > 0.28). Discussion: Both chronic whiplash-associated disorders and idiopathic neck pain groups were characterized by mechanical hyperalgesia over the cervical spine. Whiplash subjects showed additional widespread hypersensitivity to mechanical pressure and thermal stimuli, which was independent of state anxiety and may represent changes in central pain processing mechanisms. This may have implications for future treatment approaches.

Are the changes in postural control associated with low back pain caused by pain interference?

Background: Voluntary limb movements are associated with involuntary and automatic postural adjustments of the trunk muscles. These postural adjustments occur prior to movement and prevent unwanted perturbation of the trunk. In low back pain, postural adjustments of the trunk muscles are altered such that the deep trunk muscles are consistently delayed and the superficial trunk muscles are sometimes augmented. This alteration of postural adjustments may reflect disruption of normal postural control imparted by reduced central nervous system resources available during pain, so-called pain interference, or reflect adoption of an alternate postural adjustment strategy. Methods: We aimed to clarify this by recording electromyographic activity of the upper (obliquus extemus) and lower (transversus abdominis/obliquus internus) abdominal muscles during voluntary arm movements that were coupled with painful cutaneous stimulation at the low back. If the effect of pain on postural adjustments is caused by pain interference, it should be greatest at the onset of the stimulus, should habituate with repeated exposure, and be absent immediately when the threat of pain is removed. Sixteen patients performed 30 forward movements of the right arm in response to a visual cue (control). Seventy trials were then conducted in which arm movement was coupled with pain (pain trials) and then a further 70 trials were conducted without the pain stimulus (no pain trials). Results: There was a gradual and increasing delay of transversus abdominis/obliquus internus electromyograph and augmentation of obliquus externus during the pain trials, both of which gradually returned to control values during the no pain trials. Conclusion: The results suggest that altered postural adjustments of the trunk muscles during pain are not caused by pain interference but are likely to reflect development and adoption of an alternate postural adjustment strategy, which may serve to limit the amplitude and velocity of trunk excursion caused by arm movement.