PHYSICAL THERAPY Tool for Pain Management...Describe how care managers can address common barriers to referral and participation in Physical Therapy ... CASE STUDY #1 From APTA White

A Valuable Tool for Pain Management

PHYSICAL THERAPY

� Identify evidence based non-pharmacologic interventions for chronic pain.

� Describe the ways in which Physical Therapy can skillfully deliver evidence based interventions for pain.

� Describe how care managers can address common barriers to referral and participation in Physical Therapy

� Il lustrate how care manager’s knowledge of the specific interventions employed in physical therapy can support the patient’s recovery.

OBJECTIVES

PAIN SEVERITY / INTENSITY

� 10/10 pain, 20/10 pain, etc

� A key determinant of disability and it can be an obstacle to resuming normal activity

• Its not justnot justnot justnot just AND not evennot evennot evennot even measuring nociception

• It reflects suffering, perceived threat, perceived suffering, perceived threat, perceived suffering, perceived threat, perceived suffering, perceived threat, perceived control, distress, fear, context, etccontrol, distress, fear, context, etccontrol, distress, fear, context, etccontrol, distress, fear, context, etc.

• Makes sense since pain is a PRODUCTPRODUCTPRODUCTPRODUCT of all these & more

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Copyright (©2007) University of Keele: funded by Arthritis Research UK

� PEG Tool1

1. Pain on Average

2. Pain interference: a.a.a.a. Enjoyment of LifeEnjoyment of LifeEnjoyment of LifeEnjoyment of Life

3. Pain interference: a.a.a.a. General ActivityGeneral ActivityGeneral ActivityGeneral Activity

� Useful for tracking change over time

� 3 point change is valid

SHIFT TOWARD FUNCTION

1Krebs EE, Lorenz KA, Bair MJ, et al. Development and Initial Validation of the PEG, a Three-item Scale Assessing Pain Intensity and Interference. Journal of General Internal Medicine. 2009;24(6):733-738. doi:10.1007/s11606-009-0981-1.

Mi-CCSI Care Management Care Review Collaborative Presentation | Dave Williams PhD | February 16, 2018

EVIDENCE BASED PRACTICE

Physical TherapyPhysical TherapyPhysical TherapyPhysical Therapy

Psychologically Informed Care

• Determines if pain is of mechanical nature or red flag origin

Treatment: changes posture, strength, body mechanics in accordance with stages of healing. eg. Exercise, manual therapy, education, McKenzie

PSYCHOLOGICALLY INFORMED CARE

Screen for modifiablemodifiablemodifiablemodifiablepsychosocial targets

� Depression� Fear Avoidance-

Kinesiophobia� Catastrophizing� Anxiety� Faulty Beliefs

Pillars-

1. Motivational Interviewing

2. Neuroscience of Pain3. Behavior Modification

• CBT• ACT• Operant Conditioning• Graded Exposure

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PAIN & PT

� Low back pain. Low back pain. Low back pain. Low back pain. A review of >60 randomized controlled trials (RCTs) evaluating exercise therapy for adults with low back pain found that such treatment can decrease pain, improve decrease pain, improve decrease pain, improve decrease pain, improve function, and help people return to work.function, and help people return to work.function, and help people return to work.function, and help people return to work.2

� Before & after surgery. Before & after surgery. Before & after surgery. Before & after surgery. A review of 35 RCTs (~3,000 patients) found that in patients undergoing THA: preoperative exercise and education led to significant significant significant significant reductions in pain, shorter lengths of stay postoperatively and reductions in pain, shorter lengths of stay postoperatively and reductions in pain, shorter lengths of stay postoperatively and reductions in pain, shorter lengths of stay postoperatively and improvements in functionimprovements in functionimprovements in functionimprovements in function.3

� Arthritis. Arthritis. Arthritis. Arthritis. Studies have shown that therapeutic exercise programs can reduce pain and improve physical function reduce pain and improve physical function reduce pain and improve physical function reduce pain and improve physical function among individuals with hip and knee osteoarthritis.4,5

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� Pain is always realPain is always realPain is always realPain is always real, but not always the result of a physical injury.

� The brain is constantly The brain is constantly The brain is constantly The brain is constantly asking: asking: asking: asking:

� How dangerousdangerousdangerousdangerous is this?� Constantly scanning the body

and environment for potential threats.

� The brain notices a threat and reacts with a pain sensation.

• Sometimes the brain continues to send a pain signal long after the injury has healed for several reasons:

• Increased stress and anxiety from:• Not knowing the cause of the

pain • Not knowing how long the pain

will last• Unsuccessful pain treatments • Pain limiting normal activity

BEST EVIDENCE: EDUCATION

Neuroscience of PainNeuroscience of PainNeuroscience of PainNeuroscience of Pain6

Nerves send messages to your brain and your brain decides how much pain you feel—a lotlotlotlot, , , , a littlea littlea littlea little, , , , or none at all . or none at all . or none at all . or none at all .

HOWEVER,HOWEVER,HOWEVER,HOWEVER,

“Information is to behavioural change as spaghetti is to a brick” William Fordyce

�PT intervention is mostly concerned with changing actual behavior not necessarily cognitions

BEST EVIDENCE: CBT

Experiential Learning Facilitated in PT�Exercise or Activities of Daily Living Despite Pain7

� Modification of movement: patient is taught strategies to complete common tasks with minimal or no pain

� When Task is completed successfully:� Undermines Catastrophic thinking, fear avoidant behaviors

�Pre-determined task termination:8

� If symptomatic (or pain above baseline) at 30 min of activity:� Schedule 10 min of that activity throughout the day – so that feared

consequence (pain spike) never occurs but they are productive

�Frequency of exposure is key to changing behavior� Schedule activity 3-6 times per day.� Change behavior long enough and belief emerges.

BEST EVIDENCE: EDUCATION

0

1

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Boom / Bust CycleBoom / Bust CycleBoom / Bust CycleBoom / Bust Cycle

Activity0

1

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9Pacing / Graded Activity Pacing / Graded Activity Pacing / Graded Activity Pacing / Graded Activity 9,10,11

Activity

Avg: 3 hrs/ week

BEST EVIDENCE: EDUCATION

Activity tolerance

Avg: 2 hrs/ week

� Physical Therapy can help safely dose patients with aerobic exercise according to their specific needs, coaccording to their specific needs, coaccording to their specific needs, coaccording to their specific needs, co----morbidities, and morbidities, and morbidities, and morbidities, and

patient preferencespatient preferencespatient preferencespatient preferences12,13

BEST EVIDENCE: AEROBIC EXERCISE

Evidence Based Formats :• Graded exposure• Rating of Perceived Exertion

scale (RPE)• 6-7 is the target for

ef fort that produces optimal resultsoptimal resultsoptimal resultsoptimal results

• To foster patient engagement: may start lower… however, too low jeopardizes results.

Evidence Based Formats:�High Intensity Interval Training (HIIT)14,15,16

� Can start smaller to be palatable to patients

BEST EVIDENCE: AEROBIC EXERCISE

Evidence Based Formats:Decreasing Intensity17

�Warm up

�Most intense effort

�Decreasing over time

BEST EVIDENCE: AEROBIC EXERCISE

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Time (min)Time (min)Time (min)Time (min)

Workout SessionWorkout SessionWorkout SessionWorkout Session

� Physical Therapy can evaluate for weakness and deconditioning that is increasing the demand on a patient to complete their ADL’s.

� Sit to stand� Stair climbing� Lift / push / pull / carry.

� Pro’s18,19

� Efficient: frequency can be 1-2 times a week� Useful when patient has access and a history of strength training� Endogenous opiate release

� Con’s� Dose/response carefully monitored and scripted to not further

sensitize patient to becoming active.

MODERATE EVIDENCE:STRENGTH TRAINING

Cognitive Behavioral TherapyCognitive Behavioral TherapyCognitive Behavioral TherapyCognitive Behavioral Therapy principles/ strategies (as well as other evidence based

psychological/behavioral interventions, eg. ACT) have been successfully blended with the

traditional PT skillset over the past years.20-24

BEST EVIDENCE: CBT

PSYCHOLOGICALLY INFORMED CARE & PT

Sullivan et al. (2010)Sullivan et al. (2010)Sullivan et al. (2010)Sullivan et al. (2010)25252525

� Patients who participated in the psychosocial intervention in psychosocial intervention in psychosocial intervention in psychosocial intervention in addition to physiotherapy showed significantly greater addition to physiotherapy showed significantly greater addition to physiotherapy showed significantly greater addition to physiotherapy showed significantly greater reductionsreductionsreductionsreductions in pain catastrophizing, fear of movement, and pain catastrophizing, fear of movement, and pain catastrophizing, fear of movement, and pain catastrophizing, fear of movement, and

depressiondepressiondepressiondepression than patients who received only the physiotherapy intervention.

� Reductions in psychosocial risk factors contributed to reduced use of the health care system, reduced use of pain reduced use of the health care system, reduced use of pain reduced use of the health care system, reduced use of pain reduced use of the health care system, reduced use of pain

medication, and improved returnmedication, and improved returnmedication, and improved returnmedication, and improved return---- totototo----work outcomes.work outcomes.work outcomes.work outcomes.

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PIC PT VS. TRADITIONAL PT

BodesBodesBodesBodes----Pardo et . a l . Pardo et . a l . Pardo et . a l . Pardo et . a l . (2018, RCT) 26262626

� Combining pain neurophysiology educat ion (PNE) with exercise (TE) Combining pain neurophysiology educat ion (PNE) with exercise (TE) Combining pain neurophysiology educat ion (PNE) with exercise (TE) Combining pain neurophysiology educat ion (PNE) with exercise (TE)

resulted in s ignif icant ly better results for par t ic ipants with CLBP, with a resulted in s ignif icant ly better results for par t ic ipants with CLBP, with a resulted in s ignif icant ly better results for par t ic ipants with CLBP, with a resulted in s ignif icant ly better results for par t ic ipants with CLBP, with a

large ef fect s ize, large ef fect s ize, large ef fect s ize, large ef fect s ize, compared with TE alone (moderate ef fect for secondary variables.

Malfl ietMalfl ietMalfl ietMalfl iet , et al . , et al . , et al . , et al . (2018 RCT in JAMA Neurology ) 27272727

� Pain neuroscience educat ion combined with cognit ionPain neuroscience educat ion combined with cognit ionPain neuroscience educat ion combined with cognit ionPain neuroscience educat ion combined with cognit ion ---- targeted motor targeted motor targeted motor targeted motor

control t raining appears to be more ef fect ive than current bestcontrol t raining appears to be more ef fect ive than current bestcontrol t raining appears to be more ef fect ive than current bestcontrol t raining appears to be more ef fect ive than current best ----evidence evidence evidence evidence

physiotherapy physiotherapy physiotherapy physiotherapy for improving pain, symptoms of central sensit ization, disabi l i ty, mental and physical functioning, and pain cognit ions in individuals with chronic spinal pain.

VibeVibeVibeVibe ----FersumFersumFersumFersum, et . a l . , et . a l . , et . a l . , et . a l . (2013 RCT) 28282828

� The classif icat ionThe classif icat ionThe classif icat ionThe classif icat ion ----based based based based cognit ive funct ional therapy group cognit ive funct ional therapy group cognit ive funct ional therapy group cognit ive funct ional therapy group displayed displayed displayed displayed signif icant ly superior outcomessignif icant ly superior outcomessignif icant ly superior outcomessignif icant ly superior outcomes to the manual therapy and exercise to the manual therapy and exercise to the manual therapy and exercise to the manual therapy and exercise group, both stat ist ical ly (pgroup, both stat ist ical ly (pgroup, both stat ist ical ly (pgroup, both stat ist ical ly (p  <<<<  0.001) and 0.001) and 0.001) and 0.001) and cl inical ly.c l inical ly.c l inical ly.c l inical ly.

� Oswestr yOswestr yOswestr yOswestr y D isabi l i ty IndexD isabi l i ty IndexD isabi l i ty IndexD isabi l i ty Index : : : : cognitive functional therapy group improved by 13.7 cognitive functional therapy group improved by 13.7 cognitive functional therapy group improved by 13.7 cognitive functional therapy group improved by 13.7

points vs. 5.5 pointspoints vs. 5.5 pointspoints vs. 5.5 pointspoints vs. 5.5 points

• Pain in tensi tyPa in in tensi tyPa in in tensi tyPa in in tensi ty : cognitive functional therapy improved by 3.2 points vs. 1.5 points.cognitive functional therapy improved by 3.2 points vs. 1.5 points.cognitive functional therapy improved by 3.2 points vs. 1.5 points.cognitive functional therapy improved by 3.2 points vs. 1.5 points.19

CASE STUDIES

� Jean, a 73-year-old woman, has been taking Percocet daily for several years after being diagnosed with degenerative changes in her neck, back, knees, and feet.

� She has been seen by PTs several times intermittently in the past, but the prescribed treatments haven’t been sustainable, while the pills of fered her some immediate—if less than satisfactory—pain relief.

� Jean now presents for an initial visit with a PT with a goal of discontinuing the Percocet.

CASE STUDY #1

From APTA Whi te Paper “Beyond Opioids : How Phys ica l Therapy Can Transform Pain Management to Improve Heal th . ” June 1 , 2018 29

� She offers that her granddaughter is a supportive caregiver who can be counted on to assist in her plan of care.

� Upon examination, the PT determines that Jean has generalized weakness, poor balance, poor fitness, fair overall health, and dif ficulties with performing activities of daily l iving.

� Jean also has developed some fear of movement and expresses a great deal of stress associated with her longstanding condition.

CASE STUDY #1

� The PT determines that an integrated plan of treatment will be most beneficial to Jean, combining physical therapist interventions with fitness, such as yoga, and behavioral health strategies.

� The PT identifies community resources and works with Jean and her granddaughter to identify beneficial programs at the local senior center that are compatible with their schedules.

� The PT develops a comprehensive pain treatment strategy beginning with an evaluation of how effectively Jean’s current use of pain medication addresses her chronic conditions.

CASE STUDY #1: TREATMENT FOCUS

� The approach then is to create a model of sustainability that Jean can achieve through her work with the PT.

� Jean will transition into self-management to avoid sliding back into heavy medication use.

� Steps will include managing Jean’s chronic conditions to lessen her periods of active pain, educating her about her pain, and building strength, balance, and endurance to improve her overall health.

� Peer support for behavior changes also are part of the plan.

� The PT involves Jean’s granddaughter in her treatment plan and sessions in order to promote a smooth transition from skilled therapy.

CASE STUDY #1: TREATMENT FOCUS

� Jean no longer takes pain medication routinely, l imiting her use to the occasional situation in which her pain is exacerbated.

� At other times, she self-manages her conditions by participating in gym workouts and group yoga classes, often enjoying those times with her granddaughter, who is pleased to see her grandmother more active and healthy.

CASE STUDY #1: OUTCOME

� Clif f is a 63-year-old male with chronic pain resulting from a series of 7 surgeries over the past 8 years, not all of them successful.

� Cliff’s surgeries include a failed meniscal repair of the right knee, a failed implant in the right great toe for arthritis, 3 surgeries to repair traumatic fractures of both ankles, surgical repair of a left elbow fracture, and surgical repair of a left wrist fracture.

� He rates his pain level at 7 out of 10, despite taking 10 325m Vicodin daily.

� He indicates that he has little energy and that loss of appetite and nausea affect his eating habits.

CASE STUDY #2

From APTA Whi te Paper “Beyond Opioids : How Phys ica l Therapy Can Transform Pain Management to Improve Heal th . June 1 , 2018

� As a member of an interprofessional team including an opioid-addiction specialist, the PT works with Clif f to develop a plan of care that will move Clif f from being pain-centric to function-centric as soon as possible.

� With Clif f’s long history of pain and resulting dependence on Vicodin, the team works together to address the effects of opioid withdrawal as a component of the overall treatment plan. This includes monitoring and addressing withdrawal symptoms while incorporating techniques that will improve Clif f’s function without increasing his pain.

CASE STUDY #2- TREATMENT FOCUS

� For the best chance of success, the team involves Clif f up front in treatment decisions to determine which strategies have worked—and which have failed, gaining his confidence and trust in the plan of care.

� Treatment begins right away, and while the first few weeks are challenging, as Clif f adjusts to being off the Vicodin he is able to better tolerate his exercises and improve his functional performance.

CASE STUDY #2- TREATMENT FOCUS

� Clif f states that the results of his treatment are “unbelievable.” Following the collaborative plan of care, his pain symptoms have decreased by 80%, he has increased energy, and his appetite has improved.

CASE STUDY #2- OUTCOMES

APPLICATION

Chronic Pain

�Setting Proper Expectations� Time

� 6+ months not 6 visits

� Neuroplasticchanges take time

� Setbacks are to be expected� Focus is on building

Resilience

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Patient ProgressPatient ProgressPatient ProgressPatient Progress

LIFE IS CURVY

� During & Post Exercise Sensations� Any negativenegativenegativenegative or unknownunknownunknownunknown experience is reason enough to stop

activity

� Please explore with your patient:� Activity dosage errors: too much, too soon, for too long.� Hurt vs harm… � Specifically: delayed onset muscle soreness (DOMS): lactic acid

soreness

� Post exercise hyperalgesia� Common with a sensitized nervous system� Malaise after exercise instead of the expected endogenous opiate

release� Will take ~3 weeks of consistent training to optimize metabolism of

cellular waste products: then normal lactic acid soreness emerges.� Normalizing the experience without dismissing it.

� Forecasting is essential to decreasing anxiety around activityForecasting is essential to decreasing anxiety around activityForecasting is essential to decreasing anxiety around activityForecasting is essential to decreasing anxiety around activity

FRAMING

� Sleep Deficits� Sleep Hygiene: education

� Sleep Apnea: central vs obstructive: referral

� Comorbid Conditions� COPD, Asthma, DM II, HTN

smoking, etc.

� Medication/Inhaler dosing and compliance

� Psychosocial and Psychiatric health

OPTIMIZING HEALTH

I’m 80 yrs oldI’m 80 yrs old

SUMMARY

� PT can utilize evidence based treatments that are highly effective for both Acute and Chronic pain.

� Psychologically Informed Care and Neuroscience education is a growing specialty with PT.

� PT can provide valuable patient education and experiential learning in regard to activity.

� PT can address acute and chronic pain episodes, within the context of other chronic disease burden.

� Care Management plays an important role in supporting the patient and PT plan of care through exploring activity dosage, barriers to activity, and forming accurate expectations for progress.

SUMMARY

�How to refer:� Psychologically Informed Care (PT)

� Therapeutic Neuroscience Education (TNE)

� Pain Science / Neuroscience of Pain

� Therapeutic Pain Specialist (TPS)

� Biopsychosocial Management of Pain

� CBT and PT

� Pain Neurophysiology Education (PNE)

ACCESS

REFERENCES

1 . K r e b s E E , L o r e n z K A , B a i r M J , e t a l . D e v e l o p m e n t a n d I n i t i a l V a l i d a t i o n o f t h e P E G , a T h r e e - i t e m S c a l e A s s e s s i n g P a i n I n t e n s i t y a n d I n t e r f e r e n c e . J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e . 2 0 0 9 ; 2 4 ( 6 ) : 7 3 3 - 7 3 8 . d o i : 1 0 . 1 0 0 7 / s 1 1 6 0 6 - 0 0 9 - 0 9 8 1 - 1 .

2 . H a y d e n J A , v a n T U l d e r M W , M a l m i v a a r a A , K o e s B W . E x e r c i s e t h e r a p y f o r t r e a t m e n t o f n o n - s p e c i f i c l o w b a c k p a i n . C o c h r a n e D a t a b a s e S y s t R e v . 2 0 0 5 ; J u l 2 0 ( 3 ) : C D 0 0 0 3 3 5 . h t t p s : / / w w w . n c b i . n l m . n i h . g o v / pu bm e d / 1 6 0 3 4 8 5 1 . A c c e s s e d A p r i l 2 , 2 0 1 8 .

3 . M o v e r R , I k e r t K , L o n g K , M a r s h J . T h e v a l u e o f p r e o p e r a t i v e e x e r c i s e a n d e d u c a t i o n f o r p a t i e n t s u n d e r g o i n g t o t a l h i p a n d k n e e a r t h r o p l a s t y : a s y s t em a t i c r e v i e w a n d m e t a - a n a l y s i s . J B J S R e v . 2 0 1 7 ; 5 ( 1 2 ) : e 2 . h t t p s : / / w w w . n c b i . n l m . n i h . g o v / p ub m e d / 2 9 2 3 2 2 6 5 . A c c e s s e d A p r i l 2 , 2 0 1 8 .

4 . F r a n s e n M , M c C o n n e l l S , H e r n a n de z - M o l i n a G , R e i c h e n b a c h S . E x e r c i s e f o r o s t e o a r t h r i t i s o f t h e h i p . C o c h r a n e D a t a b a s e S y s t R e v . 2 0 1 4 ; 2 2 ( 4 ) : C D 0 0 7 9 1 2 . h t t p s : / / w w w . n c b i . n l m . n i h . g o v / pu bm e d / 2 4 7 5 6 8 9 5 . A c c e s s e d A p r i l 2 , 2 0 1 8 .

5 . M e s s i e r S P , M i h a l k o S L , L e g a u l t C , e t a l . E f f e c t s o f i n t e n s i v e d i e t a n d e x e r c i s e o n k n e e j o i n t l o a d s , i n f l a m m a t i o n , a n d c l i n i c a l o u t c o m e s a m o n g o v e r w e i g h t a n d o b e s e a d u l t s w i t h k n e e o s t e o a r t h r i t i s : t h e I D E A r a n d o m i z e d c l i n i c a l t r i a l . J A M A . 2 0 1 3 ; 3 1 0 ( 1 2 ) : 1 2 6 3 - 7 3 . h t t p s : / / w w w . n c b i . n l m . n i h . g o v / pu bm e d / 2 4 0 6 5 0 1 3 / . A c c e s s e d A p r i l 2 , 2 0 1 8 .

6 . L o u w A , Z i m n e y K , P u e n t e du r a E J , D i e n e r I . T h e e f f i c a c y o f p a i n n e u r o s c i e n c e e d u c a t i o n o n m u s c u l o s k e l e t a l p a i n : A s y s t e m a t i c r e v i e w o f t h e l i t e r a t u r e . P h y s i o t h e r T h e o r y P r a c t . 2 0 1 6 J u l ; 3 2 ( 5 ) : 3 3 2 - 5 5 . d o i : 1 0 . 1 0 8 0 / 0 9 5 9 3 9 8 5 . 2 0 1 6 . 1 1 9 4 6 4 6 . E p u b 2 0 1 6 J u n 2 8 . R e v i e w . P u b M e d P M I D : 2 7 3 5 1 5 4 1 .

7 . L e h m a n G J . T h e R o l e a n d V a l u e o f S y m p t o m - M o d i f i c a t i o n A p p r o a c h e s i n M u s c u l o s k e l e t a l P r a c t i c e . J O r t h o p S p o r t s P h y s T h e r . 2 0 1 8 J u n ; 4 8 ( 6 ) : 4 3 0 - 4 3 5 .

8 . W i d e m a n T H , S u l l i v a n M J . R e d u c i n g c a t a s t r o p h i c t h i n k i n g a s s o c i a t e d w i t h p a i n . P a i n M a n a g . 2 0 1 1 M a y ; 1 ( 3 ) : 2 4 9 - 5 6 . d o i : 1 0 . 2 2 1 7 / p m t . 1 1 . 1 4 . P u b M e d P M I D : 2 4 6 4 6 3 9 1 .

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9 . S c o t t - D e m p s t e r C , T o y e F , T r u m a n J , B a r k e r K . P h y s i o t h e r a p i s t s ' e x p e r i e n c e s o f a c t i v i t y p a c i n g w i t h p e o p l e w i t h c h r o n i c m u s c u l o s k e l e t a l p a i n : a n i n t e r p r e t a t i v e p h e n o m e n o l o g i c a l a n a l y s i s . P h y s i o t h e rT h e o r y P r a c t . 2 0 1 4 J u l ; 3 0 ( 5 ) : 3 1 9 - 2 8 . d o i : 1 0 . 3 1 0 9 / 0 9 5 9 3 9 8 5 . 2 0 1 3 . 8 6 9 7 7 4 . E p u b 2 0 1 3 D e c 3 0 . P u b M e d P M I D : 2 4 3 7 7 6 6 4 .

1 0 . A n d r e w s N E , S t r o n g J , M e r e d i t h P J . A c t i v i t y p a c i n g , a v o i d a n c e , e n d u r a n c e , a n d a s s o c i a t i o n s w i t h p a t i e n t f u n c t i o n i n g i n c h r o n i c p a i n : a s y s t e m a t i c r e v i e w a n d m e t a - a n a l y s i s . A r c h P h y s M e d R e h a b i l . 2 0 1 2 N o v ; 9 3 ( 1 1 ) : 2 1 0 9 - 2 1 2 1 . e 7 . d o i : 1 0 . 1 0 1 6 / j . a p m r . 2 0 1 2 . 0 5 . 0 2 9 . E p u b 2 0 1 2 J u n 2 1 . R e v i e w . P u b M e d P M I D : 2 2 7 2 8 6 9 9 .

1 1 . A n d r e w s N E , S t r o n g J , M e r e d i t h P J . O v e r a c t i v i t y i n c h r o n i c p a i n : i s i t a v a l i d c o n s t r u c t ? P a i n . 2 0 1 5 O c t ; 1 5 6 ( 1 0 ) : 1 9 9 1 - 2 0 0 0 . d o i : 1 0 . 1 0 9 7 / j . p a i n . 0 0 0 0 0 0 0 0 0 0 0 0 0 2 5 9 . P u b M e d P M I D : 2 6 0 6 7 5 8 3 ; P u b M e d C e n t r a l P M C I D : P M C 4 7 7 0 3 3 1 .

1 2 . B i d o n d e J , B u s c h A J , S c h a c h t e r C L , O v e r e n d T J , K i m S Y , G ó e s S M , B o d e n C , F o u l d s H J . A e r o b i c e x e r c i s e t r a i n i n g f o r a d u l t s w i t h f i b r o m y a l g i a . C o c h r a n e D a t a b a s e S y s t R e v . 2 0 1 7 J u n 2 1 ; 6 : C D 0 1 2 7 0 0 .

1 3 . Ö t e K a r a c a Ş , D e m i r s o y N , G ü n e n d i Z . E f f e c t s o f a e r o b i c e x e r c i s e o n p a i n s e n s i t i v i t y , h e a r t r a t e r e c o v e r y , a n d h e a l t h - r e l a t e d q u a l i t y o f l i f e i n p a t i e n t s w i t h c h r o n i c m u s c u l o s k e l e t a l p a i n . I n t J R e h a b i l R e s . 2 0 1 7 J u n ; 4 0 ( 2 ) : 1 6 4 - 1 7 0 . d o i : 1 0 . 1 0 9 7 / M R R . 0 0 0 0 0 0 0 0 0 0 0 0 0 2 1 2 . P u b M e d P M I D : 2 8 0 4 5 8 6 5 .

1 4 . O ' L e a r y T J , C o l l e t t J , H o w e l l s K , M o r r i s M G . H i g h b u t n o t m o d e r a t e - i n t e n s i t y e n d u r a n c e t r a i n i n g i n c r e a s e s p a i n t o l e r a n c e : a r a n d o m i s e d t r i a l . E u r J A p p l P h y s i o l . 2 0 1 7 N o v ; 1 1 7 ( 1 1 ) : 2 2 0 1 - 2 2 1 0 . d o i : 1 0 . 1 0 0 7 / s 0 0 4 2 1 - 0 1 7 - 3 7 0 8 - 8 . E p u b 2 0 1 7 S e p 6 . P u b M e d P M I D : 2 8 8 7 9 6 1 7 .

1 5 . H w a n g C L , Y o o J K , K i m H K , H w a n g M H , H a n d b e r g E M , P e t e r s e n J W , C h r i s t o u D D . N o v e l a l l - e x t r e m i t y h i g h -i n t e n s i t y i n t e r v a l t r a i n i n g i m p r o v e s a e r o b i c f i t n e s s , c a r d i a c f u n c t i o n a n d i n s u l i n r e s i s t a n c e i n h e a l t h y o l d e r a d u l t s . E x p G e r o n t o l . 2 0 1 6 S e p ; 8 2 : 1 1 2 - 9 . d o i : 1 0 . 1 0 1 6 / j . e x g e r . 2 0 1 6 . 0 6 . 0 0 9 . E p u b 2 0 1 6 J u n 2 1 . P u b M e d P M I D : 2 7 3 4 6 6 4 6 ; P u b M e d C e n t r a l P M C I D : P M C 4 9 7 5 1 5 4 .

1 6 . V e l l a C A , T a y l o r K , D r u m m e r D . H i g h - i n t e n s i t y i n t e r v a l a n d m o d e r a t e - i n t e n s i t y c o n t i n u o u s t r a i n i n g e l i c i t s i m i l a r e n j o y m e n t a n d a d h e r e n c e l e v e l s i n o v e r w e i g h t a n d o b e s e a d u l t s . E u r J S p o r t S c i . 2 0 1 7 O c t ; 1 7 ( 9 ) : 1 2 0 3 - 1 2 1 1 . d o i : 1 0 . 1 0 8 0 / 1 7 4 6 1 3 9 1 . 2 0 1 7 . 1 3 5 9 6 7 9 . E p u b 2 0 1 7 A u g 9 . P u b M e d P M I D : 2 8 7 9 2 8 5 1 ; P u b M e d C e n t r a l P M C I D : P M C 6 1 0 4 6 3 1 .

1 7 . Z e n k o Z , E k k e k a k i s P , A r i e l y D . C a n Y o u H a v e Y o u r V i g o r o u s E x e r c i s e a n d E n j o y I t T o o ? R a m p i n g I n t e n s i t y D o w n I n c r e a s e s P o s t e x e r c i s e , R e m e m b e r e d , a n d F o r e c a s t e d P l e a s u r e . J S p o r t E x e r c P s y c h o l . 2 0 1 6 A p r ; 3 8 ( 2 ) : 1 4 9 - 5 9 . d o i : 1 0 . 1 1 2 3 / j s e p . 2 0 1 5 - 0 2 8 6 . E p u b 2 0 1 6 M a r 1 5 . P u b M e d P M I D : 2 7 3 9 0 1 8 5 .

1 8 . E r i c s s o n A , P a l s t a m A , L a r s s o n A , L ö f g r e n M , B i l e v i c i u t e - L j u n g a r I , B j e r s i n g J , G e r d l e B , K o s e k E , M a n n e r k o r p i K . R e s i s t a n c e e x e r c i s e i m p r o v e s p h y s i c a l f a t i g u e i n w o m e n w i t h f i b r o m y a l g i a : a r a n d o m i z e d c o n t r o l l e d t r i a l . A r t h r i t i s R e s T h e r . 2 0 1 6 J u l 3 0 ; 1 8 : 1 7 6 .

1 9 . S o s a - R e i n a M D , N u n e z - N a g y S , G a l l e g o - I z q u i e r d o T , P e c o s - M a r t í n D , M o n s e r r a t J , Á l v a r e z - M o n M . E f f e c t i v e n e s s o f T h e r a p e u t i c E x e r c i s e i n F i b r o m y a l g i a S y n d r o m e : A S y s t e m a t i c R e v i e w a n d M e t a - A n a l y s i s o f R a n d o m i z e d C l i n i c a l T r i a l s . B i o m e d R e s I n t . 2 0 1 7 ; 2 0 1 7 : 2 3 5 6 3 4 6 . d o i : 1 0 . 1 1 5 5 / 2 0 1 7 / 2 3 5 6 3 4 6 . E p u b2 0 1 7 S e p 2 0 .

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2 0 . H i l l , J C . , e t a l . C o m p a r i s o n o f s t r a t i f i e d p r i m a r y c a r e m a n a g e m e n t f o r l o w b a c k p a i n w i t h c u r r e n t b e s t p r a c t i c e ( S T a r T B a c k ) : a r a n d o m i s e d c o n t r o l l e d t r i a l . L a n c e t . 2 0 1 1 ; 3 7 8 . 9 8 0 2 : 1 5 6 0 - 1 5 7 1 .

2 1 . F o s t e r N E , e t . a l . E f f e c t o f S t r a t i f i e d C a r e f o r L o w B a c k P a i n i n F a m i l y P r a c t i c e ( I M P a C T B a c k ) : A P r o s p e c t i v e P o p u l a t i o n - B a s e d S e q u e n t i a l C o m p a r i s o n . A n n F a m M e d . M a r c h / A p r i l 2 0 1 4 1 2 : 1 0 2 -1 1 1 .

2 2 . M a i n C J , S o w d e n G , H i l l J C , W a t s o n P J , H a y E M . I n t e g r a t i n g p h y s i c a l a n d p s y c h o l o g i c a l a p p r o a c h e s t o t r e a t m e n t i n l o w b a c k p a i n : t h e d e v e l o p m e n t a n d c o n t e n t o f t h e S T a r T B a c k t r i a l ' s ‘ h i g h - r i s k ’ i n t e r v e n t i o n . P h y s i o t h e r a p y 2 0 1 2 ; 9 8 : ( 2 ) 1 1 0 - 1 1 6 .

2 3 . K a r l e n E , M c C a t h i e B . I m p l e m e n t a t i o n o f a Q u a l i t y I m p r o v e m e n t P r o c e s s A i m e d t o D e l i v e r H i g h e r -V a l u e P h y s i c a l T h e r a p y f o r P a t i e n t s W i t h L o w B a c k P a i n : C a s e R e p o r t . P h y s T h e r . 2 0 1 5 D e c ; 9 5 ( 1 2 ) : 1 7 1 2 - 2 1 .

2 4 . N i c h o l a s M K , G e o r g e S Z . P s y c h o l o g i c a l l y i n f o r m e d i n t e r v e n t i o n s f o r l o w b a c k p a i n : a n u p d a t e f o r p h y s i c a l t h e r a p i s t s . P h y s T h e r . 2 0 1 1 M a y ; 9 1 ( 5 ) : 7 6 5 - 7 6 .

2 5 . S u l l i v a n M J L , A d a m s H . P s y c h o s o c i a l t r e a t m e n t t e c h n i q u e s t o a u g m e n t t h e i m p a c t o f p h y s i o t h e r a p y i n t e r v e n t i o n s f o r l o w b a c k p a i n . P h y s i o t he r C a n . 2 0 1 0 ; 6 2 : 1 8 0 – 1 8 9

2 6 . B o d e s P a r d o G , L l u c h G i r b é s E , R o u s s e l N A , G a l l e g o I z q u i e r d o T , J i m é n e z P e n i c k V , P e c o s M a r t í n D . P a i n N e u r o p h y s i o l o g y E d u c a t i o n a n d T h e r a p e u t i c E x e r c i s e f o r P a t i e n t s W i t h C h r o n i c L o w B a c k P a i n : A S i n g l e - B l i n d R a n d o m i z e d C o n t r o l l e d T r i a l . A r c h P h y s M e d R e h a b i l . 2 0 1 8 F e b ; 9 9 ( 2 ) : 3 3 8 -3 4 7 . d o i : 1 0 . 1 0 1 6 / j . a p m r . 2 0 1 7 . 1 0 . 0 1 6 . E p u b 2 0 1 7 N o v 1 1 . P u b M e d P M I D : 2 9 1 3 8 0 4 9 .

2 7 . M a l f l i e t A , K r e g e l J , C o p p i e t e r s I , D e P a u w R , M e e u s M , R o u s s e l N , C a g n i e B , D a n n e e l s L , N i j s J . E f f e c t o f P a i n N e u r o s c i e n c e E d u c a t i o n C o m b i n e d W i t h C o g n i t i o n - T a r g e t e d M o t o r C o n t r o l T r a i n i n g o n C h r o n i c S p i n a l P a i n : A R a n d o m i z e d C l i n i c a l T r i a l . J A M A N e u r o l . 2 0 1 8 A p r 1 6 . d o i : 1 0 . 1 0 0 1 / j a m a n e u r o l . 2 0 1 8 . 0 4 9 2 . [ E p u b a h e a d o f p r i n t ] P u b M e d P M I D : 2 9 7 1 0 0 9 9 .

2 8 . V i b e F e r s u m K , O ' S u l l i v a n P , S k o u e n J S , S m i t h A , K v å l e A . E f f i c a c y o f c l a s s i f i c a t i o n - b a s e d c o g n i t i v e f u n c t i o n a l t h e r a p y i n p a t i e n t s w i t h n o n - s p e c i f i c c h r o n i c l o w b a c k p a i n : a r a n d o m i z e d c o n t r o l l e d t r i a l . E u r J P a i n . 2 0 1 3 J u l ; 1 7 ( 6 ) : 9 1 6 - 2 8 . d o i : 1 0 . 1 0 0 2 / j . 1 5 3 2 - 2 1 4 9 . 2 0 1 2 . 0 0 2 5 2 . x . E p u b2 0 1 2 D e c 4 . P u b M e d P M I D : 2 3 2 0 8 9 4 5 ; P u b M e d C e n t r a l P M C I D : P M C 3 7 9 6 8 6 6 \

2 9 . A P T A W h i t e P a p e r “ B e y o n d O p i o i d s : H o w P h y s i c a l T h e r a p y C a n T r a n s f o r m P a i n M a n a g e m e n t t o I m p r o v e H e a l t h . ” h t t p s : / / w w w . a p ta . o r g / u p l o a d e d F i l e s / A P T A o r g / A d v o c a c y / F e de r a l / L e g i s l a t i v e _ I s s u e s / O p i o i d/ A P T A Op i o i d W h i t e P a p e r . p d f

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