EMG activity normalization for trunk muscles in subjects with and without back pain

Purpose: The aims of the present study were to examine electromyographic (EMG) activity of six bilateral trunk muscles during maximal contraction in three cardinal planes, and to determine the direction of contraction that gives maximal activation for each muscle. both for healthy subjects and back-pain patients. Methods: Twenty-eight healthy subjects and 15 back-pain patients performed maximum voluntary contractions in three cardinal planes, Surface EMG signals were recorded from rectus abdominis, external oblique, internal oblique, latissimus dorsi, iliocostalis lumborum, and multifidus bilaterally. Root mean square values of the EMG data were calculated to quantify I the amplitude of EMG signals. Results: For both healthy subjects and back-pain patients. one single direction of contraction was found to give the maximum EMG signals for most muscles. Rectus abdominis demonstrated maximal activity in trunk flexion, external oblique in lateral flexion. internal oblique in axial rotation, and multifidus in extension. For the latissimus dorsi and iliocostalis lumborum. maximal activity was demonstrated in more than one cardinal plane. Conclusion: This study has implications for future research involving normalization of muscle activity to maximal levels required in many trunk EMG studies. As the latissimus dorsi and iliocostalis lumborum demonstrate individual differences in the plane that gives maximal activity, these muscles may require testing in more than one plane.

Adaptação cultural e contributo para a validação da escala petterns of activity measura - pain (POAM-P)

RESUMO: A dor lombar crónica (DLC) é uma das condições clínicas mais comuns e com elevados custos socioeconómicos no mundo ocidental. Estudos recentes indicam que os utentes com DLC apresentam diferentes padrões de atividade que influenciam os níveis de incapacidade funcional. Contudo, a evidência acerca destas associações é, ainda, limitada e inconclusiva. Em Portugal, não existe, do nosso conhecimento, nenhuma escala validada para a população portuguesa que meça estes padrões de atividade em utentes com DLC. Objetivos: Adaptar culturalmente a escala Patterns of Activity Measure – Pain (POAM-P) para a população portuguesa com dor lombar crónica inespecífica (DLCI) e contribuir para a sua validação. Metodologia: A versão original (inglesa) do POAM-P foi traduzida e adaptada para a língua portuguesa (POAM-P-VP) através de uma equipa multidisciplinar que incluiu tradutores, retrotradutores (cegos e independentes), peritos de diferentes áreas e utentes com DLCI, de acordo com as recomendações de linhas orientadoras atuais para este processo. A análise factorial e das propriedades psicométricas da POAM-P-VP contou com uma amostra de 132 utentes. A consistência interna foi analisada através do coeficiente alpha de Cronbach (α) e para a análise da fiabilidade teste-reteste recorreu-se ao coeficiente de correlação intraclasse (ICC:2,1). A análise da validade de construto convergente e discriminativa das componentes da POAM-P-VP foi conseguida através da aplicação da versão portuguesa da escala Tampa Scale of Kinesiophobia (TSK-13-VP), e recorrendo ao cálculo do coeficiente de Spearman. Todos os cálculos estatísticos foram realizados no software IBM SPSS Statistics (versão 20). Resultados: A análise factorial permitiu identificar três componentes da POAM-P-VP (evitamento, persistência excessiva e persistência consistente com a dor), sendo estruturalmente diferentes das subescalas do POAM-P original. Estas componentes apresentaram uma consistência interna boa a elevada. As componentes 1 e 2 apresentaram uma fiabilidade teste-reteste moderada a excelente, e a componente 3 uma fiabilidade teste-reteste pobre, limitando o seu poder de uso na prática clínica e em investigação. Relativamente à validade de construto, nenhuma das hipóteses estabelecidas no estudo apriori foram verificadas, não podendo aferir acerca da relação dos padrões de atividade com a cinesiofobia, medida pelo TSK-13-VP. Porém, a componente de evitamento da POAM-P-VP parece medir conteúdos partilhados com a TSK-13-VP (rs = 0.15, p<0.048). Conclusão: A adaptação e contributo para a validação da versão portuguesa da escala POAM-P constituiu um ponto de partida para a existência de um instrumento de medição de padrões de atividade de utentes portugueses com DLC, requerendo mais estudos para a sua validação. Apesar de algumas limitações, considera-se que este estudo é de grande importância para os fisioterapeutas e investigadores que buscam um maior conhecimento e efetividade das abordagens de intervenção em utentes com dor lombar crónica.-------------- ABSTRACT: Chronic low back pain (CLBP) is one of the most common clinical conditions as well as one with high economical costs within western countries. Recent studies have shown that patients with LBP present different patterns of activity which influence their levels of functional capacity. However, evidence on these associations is still limited and inconclusive. To our knowledge, there is in Portugal no valid scale for measuring these patterns of activity in CLBP patients. Purpose: Culturally adapt the Patterns of Activity Measure – Pain (POAM-P) scale to the Portuguese population with non-specific chronic low back pain (NSLBP) and contribute to its validation. Method: The original English version of POAM-P was blindly and independently translated, back translated and adapted to the Portuguese language (POAM-P-VP) by a multidisciplinary team of translators, experts from different fields, and patients with NSLBP, according to established guidelines for this process. Factorial and psychometric properties’ analysis of POAM-P-VP comprised a sample of 132 patients. The internal consistency was analyzed based on Cronbach's alpha-coefficient (α) and for test-retest reliability analysis the Intraclass Correlation Coefficient (ICC) was used. The analysis of convergent and discriminant construct validity of POAM-P-VP components was achieved through the use of the Portuguese version of the Tampa Scale of Kinesiophobia (TSK-13-VP), using the Spearman coefficient calculation. All statistical calculations were performed using IBM SPSS Statistics software (v.20). Results: The factor analysis allowed for the identification of three components of POAM-P-VP (avoidance, excessive persistence and pain-contingent persistence), structurally different from the original POAM-P subscales. These components demonstrated a good to high level of internal consistency. Components 1 and 2 demonstrated moderate to excellent test-retest reliability, whereas component 3 presented low test-retest reliability thus limiting its clinical and investigative use. With regard to construct validity, none of the previously established hypothesis was verified, therefore not making it possible to assess the relation between activity patterns and kinesiophobia, measured by TSK-13-VP. However, the avoidance component of POAM-P-VP seems to share measurable contents with TSK-13-VP (rs = 0.15, p<0.048). Conclusion: The adaptation and contribution to the validation of the Portuguese version of POAM-P scale, sets a starting point to the existence of a useful instrument for measuring activity patterns in Portuguese CLBP patients, requiring further studies towards its validation. Despite some limitations, this study is considered of high importance to physiotherapists as well as investigators in search of deeper knowledge and effective practical approaches on chronic low back pain patients.

Adaptação cultural e contributo para a validação da pain attitudes and believes scale for physiotherapists (PABS-PT) para a população de fisioterapeutas portugueses

RESUMO: Introdução: Vários estudos têm encontrado evidência para a relação entre as crenças e atitudes dos profissionais de saúde, a sua abordagem de tratamento, referida como orientada segundo o modelo biomédico ou modelo biopsicossocial (Bishop, 2008; Mutsaers, 2012), e os resultados obtidos. É sugerido que, no tratamento da dor lombar crónica, os profissionais que orientam o seu raciocínio e prática segundo o modelo biomédico, tendem a obter piores resultados quando comparados com os obtidos pelos profissionais que orientam o seu raciocínio e prática segundo uma abordagem biopsicossocial. Esta área de estudo tem salientado a importância de desenhar instrumentos capazes de identificar a orientação preferencial dos profissionais de saúde no tratamento da dor crónica de natureza músculo-esquelética, entre os quais se encontra a “Pain Attitudes and Beliefs Scale for Physiotherapists” (PABS-PT). Objetivo: Adaptar culturalmente a PABS-PT para a população de fisioterapeutas portugueses que intervêm em utentes com dor (lombar) crónica, e contribuir para a sua validação Metodologia: A versão original (língua inglesa) do PABS-PT foi adaptada para a língua e cultura portuguesas, através das etapas definidas nas normas orientadoras estabelecidas para este processo (Beaton et al., 2002; MAPI Institute, 2001). A avaliação das propriedades psicométricas da versão portuguesa foi realizada com recurso a uma amostra de 202 fisioterapeutas e estudantes finalistas do curso de licenciatura em Fisioterapia. Inicialmente foi realizada a análise fatorial exploratória da escala através do método das componentes principais. Posteriormente avaliou-se a consistência interna das componentes obtidas com recurso ao alpha de Cronbach (α). Para analisar a validade de constructo foram correlacionadas as componentes obtidas com a versão portuguesa da “Health Care Providers’ Pain and Impairment Relationship Scale” (HC-PAIRS), recorrendo ao cálculo do coeficiente de Spearman. Resultados: O processo de adaptação cultural não revelou dificuldades importantes sendo considerado que a versão portuguesa da PABS-PT é de fácil compreensão e preenchimento, e os seus itens adequados para avaliar as crenças e atitudes dos fisioterapeutas portugueses relativas à intervenção na dor crónica músculo-esquelética. Os resultados revelaram uma estrutura fatorial de duas componentes, identificadas com as componentes da escala original que explicam 30,96% da variância total. A consistência interna encontrada é boa, para a componente biomédica (α de Cronbach = 0,826), mas muito fraca para a componente biopsicossocial (α de Cronbach= 0,589). Relativamente à validade convergente e discriminativa, foi encontrada uma associação estatisticamente significativa e positiva, entre as componentes 1 (biomédica) da versão nportuguesa da PABS e a HC-PAIRS (Rs = 0,481, p≤ 0,005), e negativa, fraca e significativa entre a pontuação total da componente 2 (biopsicossocial) e a HC-PAIRS (Rs = -0,038, p=0,612). Conclusão: A versão portuguesa do PABS-PT é de fácil compreensão e aparenta ser um instrumento válido para a medição da orientação preferencial dos fisioterapeutas, relativamente às suas atitudes e crenças na avaliação e tratamento de utentes com dor crónica de natureza músculo-esquelética. No entanto, a componente biopsicossocial requer uma análise mais aprofundada para que possa, com rigor, ser utilizada na definição de uma orientação preferencialmente biopsicossocial.--------------ABSTRACT: Introduction: Previous studies have found a relation between the beliefs and attitudes of health professionals, their treatment approach, which can follows a biomedical or a biopsychosocial orientation (Bishop, 2008; Mutsaers, 2012), and the outcomes obtained. Therefore, is suggested that the professionals who tend to approach chronic low back pain patients according to the biomedical model have worse outcomes than professionals who use a biopsychosocial approach in there clinical reasoning. This research field has highlighted the importance of developing measures capable of identifying the preferred orientation of health professionals in the treatment of chronic pain of musculoskeletal nature, including the “Pain Attitudes and Beliefs Scale for Physiotherapists” (PABS-PT). Objective: To cross culturally adapt and validate the PABS-PT for the Portuguese population of physiotherapists. Methodology: The original version (English version) of the PABS-PT was adapted to the Portuguese language and culture, through the guidelines established for these processes (Beaton et al., 2002; MAPI Institute, 2001). The psychometric evaluation of the Portuguese version was carried out on a sample of 202 p physiotherapist and final year students of the physiotherapy course. Initially, an exploratory factorial analysis was performed through the method of the main components. Then, the internal consistence of the main components was evaluated using the Cronbach’s alpha (α). The convergent construct validity was analysed through the correlation between the obtained components of PABS-PT and the Health Care Provider’s Pain and Impairment Relationship Scale (HC-PAIRS), using the Spearmen correlation coefficient. Results: No major difficulties were found during the cultural adaptation process of PABS-PT to Portugal, which means that the Portuguese version is easy to understand and fulfill, and items are appropriated to evaluate the beliefs and attitudes of the Portuguese physiotherapists who treat chronic pain of musculoskeletal origins. The results revealed a factorial structure of two components, as the original scale, explaining 30,96% of the total variance. Internal consistence results were good, for the biomedical component (Cronbach’s α = 0,826), but very weak for the biopsychosocial componente (Cronbach’s α = 0,589). Relatively to convergent and discriminative validity, a statistically significant association was found, between the components 1 (biomedical) of the Portuguese version of PABS-PT and the HC-PAIRS (Rs= 0,481, p≤ 0,005) and negative, weak and significant between the total score of component 2 (biopsychosocial) and the HC-PAIRS (Rs = -0,038, p=0,612). Conclusion: The Portuguese Version of PABS-PT is easy to understand and seems to be a valid instrument to measure the attitudes and beliefs of physiotherapists in the management of patients with chronic low back pain. However, the biopsychosocial component requires a further deep analysis to examine a preferable biopsychosocial orientation.

Barcoding human physical activity to assess chronic pain conditions.

BACKGROUND: Modern theories define chronic pain as a multidimensional experience - the result of complex interplay between physiological and psychological factors with significant impact on patients' physical, emotional and social functioning. The development of reliable assessment tools capable of capturing the multidimensional impact of chronic pain has challenged the medical community for decades. A number of validated tools are currently used in clinical practice however they all rely on self-reporting and are therefore inherently subjective. In this study we show that a comprehensive analysis of physical activity (PA) under real life conditions may capture behavioral aspects that may reflect physical and emotional functioning.¦METHODOLOGY: PA was monitored during five consecutive days in 60 chronic pain patients and 15 pain-free healthy subjects. To analyze the various aspects of pain-related activity behaviors we defined the concept of PA 'barcoding'. The main idea was to combine different features of PA (type, intensity, duration) to define various PA states. The temporal sequence of different states was visualized as a 'barcode' which indicated that significant information about daily activity can be contained in the amount and variety of PA states, and in the temporal structure of sequence. This information was quantified using complementary measures such as structural complexity metrics (information and sample entropy, Lempel-Ziv complexity), time spent in PA states, and two composite scores, which integrate all measures. The reliability of these measures to characterize chronic pain conditions was assessed by comparing groups of subjects with clinically different pain intensity.¦CONCLUSION: The defined measures of PA showed good discriminative features. The results suggest that significant information about pain-related functional limitations is captured by the structural complexity of PA barcodes, which decreases when the intensity of pain increases. We conclude that a comprehensive analysis of daily-life PA can provide an objective appraisal of the intensity of pain.

Behavioural alteration in chronic pain: are brain glia involved?

Behavioural symptoms such as abnormal emotionality (including anxious and depressive episodes) and cognition (for instance weakened decision-making) are highly frequent in both chronic pain patients and their animal models. The theory developed in the present article posits that alterations in glial cells (astrocytes and microglia) in cortical and limbic brain regions might be the origin of such emotional and cognitive chronic pain-associated impairments. Indeed, in mood disorders (unipolar depression, anxiety disorders, autism or schizophrenia) glial changes in brain regions involved in mood control (prefrontal and cingulate cortices, amygdala and the hippocampus) have been recurrently described. Besides, glial cells have been undoubtedly identified as key actors in the sensory component of chronic pain, owing to the profound phenotypical changes they undergo throughout the sensory pathway. Hence, the possibility arises that brain astrocytes and microglia react in upper brain structures as well, mediating the related mood and cognitive dysfunctions in chronic pain. So far, only very few studies have provided results in this prospect, mainly indirectly in pain-independent researches. Nevertheless, the first scant available data seem to merge in a unified description of a brain glial reaction occurring after chronic peripheral lesion. The present article uses this scarce literature to formulate the provocative theory of a glia-driven mood and cognitive dysfunction in chronic pain, expounding upon its validity and putative therapeutical impact as well as its current limitations and expected future developments.

Patients's satisfaction concerning postoperative analgesia after caesarean section: a comparison of 4 alternative analgesic regimen

Introduction: Different routes of postoperative analgesia may be used after cesarean section: systemic, spinal or epidural [1]. Although the efficacy of these alternative analgesic regimen has already been studied [2, 3], very few studies have compared patients' satisfaction between them. Methodology: After ethical committee acceptation, 100 ASA 1 patients scheduled for an elective cesarean section were randomized in 4 groups. After a standardized spinal anesthesia (hyperbaric bupivacaine 10 mg and fentanyl 20 μg), each group had a different postoperative analgesic regimen: - Group 1: oral paracetamol 4x1 g/24 h, oral ibuprofene 3x600 mg/24 h and subcutaneous morphine on need (0.1 mg/kg 6x/24 h) - Group 2: intrathecal morphine (100 μg) and then same as Group 1 - Group 3: oral paracetamol 4x1 g/24 h, oral ibuprofene 3x600 mg/24 h and PCEA with fentanyl 5 μg/ml epidural solution - Group 4: oral paracetamol 4x1g/24 h, oral ibuprofene 3x600 mg/ 24 h and PCEA with bupivacaine 0.1% and fentanyl 2 μg/ml epidural solution After 48 hours, a specific satisfaction questionnaire was given to all patients which permitted to obtain 2 different scores concerning postoperative analgesia: a global satisfaction score (0-10) and a detailed satisfaction score (5 questions scored 0-10 with a summative score of 0-50). Both scores, expressed as mean ± SD, were compared between the 4 groups with a Kruskall-Wallis test and between each group with a Mann-Whitney test. A P-value <0.05 was considered significant. Results: Satisfaction scores Gr. 1 (n = 25) Gr. 2 (n = 25) Gr. 3 (n = 25) Gr. 4 (n = 25) P-value global (0-10) 8.2 ± 1.2 9.0 ± 1.0 7.8 ± 2.1 6.5 ± 2.5 0.0006 detailed (0-50) 40 ± 6 43 ± 5 38 ± 6 34 ± 8 0.0002 Conclusion: Satisfaction scores were significantly better in patients who received a systemic postoperative analgesia only (Groups 1 and 2) compared to patients who received systemic and epidural postoperative analgesia (Groups 3 and 4). The best scores were achieved with the combination of intrathecal morphine and multimodal systemic analgesia (Group 2) which allowed early ambulation without significant pain. Patients treated with postoperative epidural analgesia with combined local anesthetics and opioids (Group 4) obtained the worse scores (more restrictive nursing with less mobility, frequent asymmetrical block with insufficient analgesia on one side and motor block on the other)

Exercise and nonspecific low back pain: a literature review.

We reviewed the literature to clarify the effects of exercise in preventing and treating nonspecific low back pain. We evaluated several characteristics of exercise programs including specificity, individual tailoring, supervision, motivation enhancement, volume, and intensity. The results show that exercise is effective in the primary and secondary prevention of low back pain. When used for curative treatment, exercise diminishes disability and pain severity while improving fitness and occupational status in patients who have subacute, recurrent, or chronic low back pain. Patients with acute low back pain are usually advised to continue their everyday activities to the greatest extent possible rather than to start an exercise program. Supervision is crucial to the efficacy of exercise programs. Whether general or specific exercises are preferable is unclear, and neither is there clear evidence that one-on-one sessions are superior to group sessions. Further studies are needed to determine which patient subsets respond to specific characteristics of exercise programs and which exercise volumes and intensities are optimal.

Cost-utility analysis of a three-month exercise programme vs usual care following multidisciplinary rehabilitation for chronic low back pain.

OBJECTIVE: To assess the cost-utility of an exercise programme vs usual care after functional multidisciplinary rehabilitation in patients with chronic low back pain. DESIGN: Cost-utility analysis alongside a randomized controlled trial. SUBJECTS/PATIENTS: A total of 105 patients with chronic low back pain. METHODS: Chronic low back pain patients completing a 3-week functional multidisciplinary rehabilitation were randomized to either a 3-month exercise programme (n = 56) or usual care (n = 49). The exercise programme consisted of 24 training sessions during 12 weeks. At the end of functional multidisciplinary rehabilitation and at 1-year follow-up quality of life was measured with the SF-36 questionnaire, converted into utilities and transformed into quality--adjusted life years. Direct and indirect monthly costs were measured using cost diaries. The incremental cost-effectiveness ratio was calculated as the incremental cost of the exercise programme divided by the difference in quality-adjusted life years between both groups. RESULTS: Quality of life improved significantly at 1-year follow-up in both groups. Similarly, both groups significantly reduced total monthly costs over time. No significant difference was observed between groups. The incremental cost-effectiveness ratio was 79,270 euros. CONCLUSION: Adding an exercise programme after functional multidisciplinary rehabilitation compared with usual care does not offer significant long-term benefits in quality of life and direct and indirect costs.

Care related pain in rehabilitation after orthopedic trauma: An exploratory study with qualitative data.

OBJECTIVE: Care related pain (CRP) is generally under-estimated and rarely studied in rehabilitation as well as in general medecine. Beliefs about pain influence psychological distress, adjustment to pain and physical disability. In this sense, perceptions of CRP could limit recovery. This exploratory study aims to understand patients' and caregivers' subjective perceptions and beliefs about CRP. PATIENTS AND METHODS: Questionnaires about CRP were submitted to members of the interdisciplinary team of a rehabilitation hospital and to patients with musculoskeletal complaints (cross-sectional design). Twenty patients were also individually interviewed (qualitative data). Four topics were addressed: frequency of CRP, situations and procedures causing CRP, beliefs about CRP and means used to deal with CRP. RESULTS: Seventy-five caregivers and 50 patients replied to the questionnaire. CRP is a very common experience in rehabilitation and it is recognized by both groups. Generally, the situations causing CRP reflect the specificity of rehabilitation (mobilization...) and are similarly perceived by patients and caregivers, with patients considering them as more painful. Beliefs about CRP are clearly different from those usually associated with pain. Both groups point out the utilitarian and the inevitable character of CRP. They differ on that, that patients had a more positive view about CRP. They associate it more often with progress and see it as acceptable at least until a certain limit. They are also able to perceive the richness of means used by physiotherapists to help them coping with CRP. CONCLUSION: Our data may suggest new keys to motivate patient to be active in rehabilitation for example in choosing carefully arguments or words which may fit theirs' beliefs about CRP, or in using various means to manage CRP. Promoting the use of relational competences with chronic pain patients and of a patient-centred approach may also be a concern in training caregivers.

Evaluation of different occlusal splints and counselling in the management of myofascial pain dysfunction

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Clinical and MRI investigation of temporomandibular joint in major depressed patients

Objective: The aim of the present study was to describe the clinical and MRI findings of the temporomandibular joint (TMJ) in patients with major depressive disorders (MDDs) of the non-psychotic type.Methods: 40 patients (80 TMJs) who were diagnosed as having MDDs were selected for this study. The clinical examination of the TMJs was conducted according to the research diagnostic criteria and temporomandibular disorders (TMDs). The MRIs were obtained bilaterally in each patient with axial, parasagittal and paracoronal sections within a real-time dynamic sequence. Two trained oral radiologists assessed all images. For statistical analyses, Fisher's exact test and chi(2) test were applied (alpha = 0.05).Results: Migraine was reported in 52.5% of subjects. Considering disc position, statistically significant differences between opening patterns with and without alteration (p = 0.00) and between present and absent joint noises (p = 0.00) were found. Regarding muscular pain, patients with and without abnormalities in disc function and patients with and without abnormalities in disc position were not statistically significant (p = 0.42 and p = 0.40, respectively). Significant differences between mandibular pathway with and without abnormalities (p=0.00) and between present and absent joint noises (p=0.00) were observed.Conclusion: Based on the preliminary results observed by clinical and MRI examination of the TMJ, no direct relationship could be determined between MDDs and TMDs. Dentomaxillofacial Radiology (2012) 41, 316-322. doi: 10.1259/dmfr/27328352

Sleep, stress, neurocognitive profile and healthrelated quality of life in adolescents with idiopathic musculoskeletal pain

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

[Interventional pain management, indications and results]

When conservative treatment modalities provide inadequate relief, interventional techniques play an important role in the management of chronic pain patients. They are performed in diagnostic or therapeutic intention (or both) and either directly target the pain generating anatomic structure (e.g. intraarticular joint injections) or the neural structures which are thought to mediate the experience of pain (e.g. facet joint nerve blocks, spinal cord stimulation). In order to enhance precision and patient safety, these interventions are performed with image guidance; of which fluoroscopy is the most commonly used technique. CT- or Ultrasound-guided techniques are also performed. This article is an overview of the indications and results of the most commonly performed interventional techniques used in chronic pain treatment with focus on spinal interventional procedures.

A qualitative study on the role of cultural background in patients perspectives on rehabilitation

Background Low back pain (LBP) is one of the major concerns in health care. In Switzerland, musculoskeletal problems represent the third largest illness group with 9.4 million consultations per year. The return to work rate is increased by an active treatment program and saves societal costs. However, results after rehabilitation are generally poorer in patients with a Southeast European cultural background than in other patients. This qualitative research about the rehabilitation of patients with LBP and a Southeast European cultural background, therefore, explores possible barriers to successful rehabilitation. Methods We used a triangulation of methods combining three qualitative methods of data collection: 13 semi-structured in-depth interviews with patients who have a Southeast European cultural background and live in Switzerland, five semi-structured in-depth interviews and two focus groups with health professionals, and a literature review. Between June and December 2008, we recruited participants at a Rehabilitation Centre in the German-speaking part of Switzerland. Results To cope with pain, patients prefer passive strategies, which are not in line with recommended coping strategies. Moreover, the families of patients tend to support passive behaviour and reduce the autonomy of patients. Health professionals and researchers propagate active strategies including activity in the presence of pain, yet patients do not consider psychological factors contributing to LBP. The views of physicians and health professionals are in line with research evidence demonstrating the importance of psychosocial factors for LBP. Treatment goals focusing on increasing daily activities and return to work are not well understood by patients partly due to communication problems, which is something that patients and health professionals are aware of. Additional barriers to returning to work are caused by poor job satisfaction and other work-related factors. Conclusions LBP rehabilitation can be improved by addressing the following points. Early management of LBP should be activity-centred instead of pain-centred. It is mandatory to implement return to work management early, including return to adapted work, to improve rehabilitation for patients. Rehabilitation has to start when patients have been off work for three months. Using interpreters more frequently would improve communication between health professionals and patients, and reduce misunderstandings about treatment procedures. Special emphasis must be put on the process of goal-formulation by spending more time with patients in order to identify barriers to goal attainment. Information on the return to work process should also include the financial aspects of unemployment and disability.

Human experimental pain models in drug development: translational pain research

Human experimental pain models require standardized stimulation and quantitative assessment of the evoked responses. This approach can be applied to healthy volunteers and pain patients before and after pharmacological interventions. Standardized stimuli of different modalities (ie, mechanical, chemical, thermal or electrical) can be applied to the skin, muscles and viscera for a differentiated and comprehensive assessment of various pain pathways and mechanisms. Using a multi-modal, multi-tissue approach, new and existing analgesic drugs can be profiled by their modulation of specific biomarkers. It has been shown that biomarkers, for example, those related to the central integration of repetitive nociceptive stimuli, can predict efficacy of a given drug in neuropathic pain conditions. Human experimental pain models can bridge animal and clinical pain research, and act as translational research providing new possibilities for designing successful clinical trials. Proof-of-concept studies provide cheap, fast and reliable information on dose-efficacy relationships and how pain sensed in the skin, muscles and viscera are inhibited.