Background: Caffeine (CAF), whether extracted from plants or synthesised as a chemical compound, is considered the safest among other xanthine alkaloids. Novel nano-cream formulations have been successfully developed and evaluated to increase the potential of caffeine as a skin cosmeceutical, targeting the minimisation of cellulite appearance. Methods: Nano-cream formulations were prepared through a process of hot-temperature emulsification, in a variety of homogeniser combinations. Results: When chemical penetration enhancers (CPEs) (lanolin, transcutol, and propylene glycol), either alone or in combination, were incorporated into the nano-cream formulations, the permeation of CAF through skin increased. All nano-cream formulations achieved sustained delivery of CAF into and through the skin over 8 h (IVPT). Quantification of CAF from skin tissues was achieved using high-performance liquid chromatography (HPLC). The nano-cream formulation containing lanolin (LAN) showed the highest CAF permeation (8.829 ± 1.472 µg/cm2/h) through the skin compared to CAF in an aqueous solution (2.533 ± 0.480 µg/cm2/h) and a commercial CAF cellulite product with the same CAF concentration (2.827 ± 0.555 µg/cm2/h). Therefore, 2% CAF nano-cream formulation containing LAN was chosen for clinical testing. A double-blind, randomised, placebo-controlled paired trial was conducted, in which each volunteer applied active and placebo creams to the upper thighs twice daily for 12 weeks. The effect of the cream on skin appearance was monitored over 12 weeks. The primary outcome measures were reduced cellulite scores from 3.96 (95% CI: 3.16–4.76) to 2.50 (95% CI: 1.70–3.30) (active) compared with placebo from 3.88 (95% CI: 3.08–4.67) to 2.83 (95% CI: 2.03–3.63). The effect sizes (E.S.) indicated a moderate effect for the active CAF nano-cream formulation (E.S. = 0.475), while the placebo (E.S. = 0.286) had a small effect. Conclusion: We concluded that our optimised 2% CAF nano-cream formulation containing LAN offered an effective formulation strategy for enhancing skin penetration in the IVPT study. The LAN nano-cream formulation demonstrated efficacy and tolerability, both objectively and subjectively, in a human clinical trial.

Objectives: To evaluate the effect of different dosage parameters of focused-extracorporeal shock wave therapy on pain and physical function in knee osteoarthritis patients with bone marrow lesions. In addition, to investigate pathophysiological changes based on imaging and biomarker measures. Methods: Using a single-case experimental design, a total of 12 participants were randomly allocated in 4 equal groups of 3 to receive different dosages of focused-extracorporeal shock wave therapy. Each group received either 4 or 6 sessions of 1500 or 3000 shocks over 4 or 6 weekly sessions. Participants underwent repeated measurements during the baseline, intervention, and post-intervention phases for Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, aggregated locomotor function score and pressure pain threshold. Imaging and inflammatory biomarker outcomes were measured at baseline and 3 months following the intervention. Results: The group receiving the highest dosage of focused-extracorporeal shock wave therapy showed clinical improvements superior to those of participants in the other 3 groups. Statistically significant changes during the follow-up phase in contrast to baseline measurements for the WOMAC score (Tau-U= –0.88, p < 0.001), aggregated locomotor function score (Tau-U= –0.77, p = 0.002), and pressure pain threshold (Tau-U= 0.54, p = 0.03) were observed. Bone marrow lesion and inflammatory cytokines demonstrated no change. Conclusion: A dose-dependent effect for focused-extracorporeal shock wave therapy on osteoarthritis-related symptoms was suggested. However, these improvements were not associated with changes in the underlying pathophysiological mechanisms.

Numerous products and minimally-invasive procedures are available to reduce cellulite. However, there are a limited number of tools to evaluate the effects of these interventions and some are relatively complex to implement. ObjectiveThis study evaluated the reliability of a standardized grading system for scoring the overall severity of cellulite on the posterior thigh. The study evaluated inter-rater and intra-rater (test/re-test) reliability of the method and engaged in an iterative process to develop a reliable method to evaluate changes in the appearance of cellulite. MethodsThere were two stages in the validation process. The first stage was an open process without evaluator training. The second stage was a more controlled process with training given and moderator involvement to review grade selections. In the first stage, inter-rater reliability was examined across five evaluators who were asked to evaluate 24 photographs (right thighs) based on a cellulite graded severity chart. During the second stage, the same photographs were examined by paired evaluators who had received additional training. Scores were independently moderated by a third person. The inter-rater reliability and intra-rater reliability over a 4-week interval were evaluated using intraclass correlation coefficients (ICCs). ResultsTwenty-four female participants (18-51 years, mean 31.68 +/- 9.03 years) with a mean BMI of 29.04 +/- 6.52 participated in the trial. Five female evaluators completed the initial evaluations. In stage 1, the inter-rater reliability (ICC2,5) was 0.838 (95%CI:0.700-0.922) and test/retest ICC3,1 values ranged from 0.360-0.990. In stage 2, the inter-rater reliability for 2 evaluators improved to 0.978 (95%CI:0.948-0.991), and the test/retest reliability of the moderated scoring method improved to 0.993 (95%CI:0.983-0.997). ConclusionThe iterative process developed a simple and reliable method of rating cellulite severity, with excellent inter-and intra-rater reliability, based on evaluating images of cellulite against a standard set of graded severity images. A reliable method of assessing cellulite severity is essential for undertaking future clinical trials to evaluate cellulite treatments.

Astaxanthin (ASX) is a potent lipophilic antioxidant derived from the natural pigment that gives marine animals their distinctive red-orange colour and confers protection from ultraviolet radiation. Self nano-emulsifying drug delivery systems (SNEDDS) have been successfully developed and evaluated to increase the skin penetration of ASX and target its antioxidant and anti-inflammatory potential to the epidermis and dermis. SNEDDS were prepared using a low-temperature spontaneous emulsification method, and their physical characteristics, stability, antioxidant activity, and skin penetration were characterized. Terpenes (D-limonene, geraniol, and farnesol) were included in the SNEDDS formulations to evaluate their potential skin penetration enhancement. An HPLC assay was developed that allowed ASX recovery from skin tissues and quantification. All SNEDDS formulations had droplets in the 20 nm range, with low polydispersity. ASX stability over 28 days storage in light and dark conditions was improved and antioxidant activity was high. SNEDDS-L1 (no terpene) gave significantly increased ASX penetration to the stratum corneum (SC) and the epidermis-dermis-follicle region (E + D + F) compared to an ASX in oil solution and a commercial ASX facial serum product. The SNEDDS-containing D-limonene gave the highest ASX permeation enhancement, with 3.34- and 3.79-fold the amount in the SC and E + D + F, respectively, compared to a similar applied dose of ASX in oil. We concluded that SNEDDS provide an effective formulation strategy for enhanced skin penetration of a highly lipophilic molecule, and when applied to ASX, have the potential to provide topical formulations for UV protection, anti-aging, and inflammatory conditions of the skin.

A substantial evidence-practice gap exists between healthcare professionals learning about the biopsychosocial model of pain and adopting this model in clinical practice. This review aimed to explore the barriers and enablers that influence the application of a biopsychosocial approach to musculoskeletal pain in practice, from the clinicians' perspective. Qualitative evidence synthesis was used. Four electronic databases (CINAHL, EMBASE, MEDLINE, and PsycINFO) were searched. Primary qualitative studies were included if they investigated the experiences of primary healthcare professionals using a biopsychosocial model of musculoskeletal pain care in outpatient settings or their perceptions towards biopsychosocial-oriented clinical practice guidelines. After screening 6571 abstracts, 77 full-text articles were retrieved. Twenty-five studies met the eligibility criteria, reporting the experiences of 413 healthcare professionals (including general practitioners, physiotherapists, and others) spanning 11 countries. Three metathemes were identified that impact the adoption of the biopsychosocial model across the whole of health: (1) at the microlevel, healthcare professionals' personal factors, knowledge and skills, and their misconceptions of clinical practice guidelines, perception of patients' factors, and time; (2) at the mesolevel, clinical practice guideline formulation, community factors, funding models, health service provision, resourcing issues, and workforce training issues; and (3) at the macrolevel, health policy, organizational, and social factors. Synthesized data revealed multilevel (whole-of-health) barriers and enablers to health professionals adopting a biopsychosocial model of pain into practice. Awareness of these multilevel factors may help inform preimplementation preparedness and support more effective implementation of the biopsychosocial model of musculoskeletal pain into clinical practice.

Abstract Background: Exercise has been shown to reduce pain sensitivity. It is unclear whether exercise can also potentiate the endogenous analgesia and reduction in pain sensitivity produced by conditioned pain modulation (CPM) and manipulation induced analgesia (MIA).Objectives: To determine whether aerobic exercise potentiates CPM and MIA and to investigate associations between exercise induced analgesia, CPM and MIA.Design: Parallel randomised, controlled trial using computer-generated randomisation to allocate interventions. Methods: A gender-stratified convenience sample included 68 participants with lateral epicondylalgia (LE) from Perth, Western Australia, recruited between October 2017 and June 2018. Participants were allocated to receive either moderate intensity aerobic exercise (control condition, n=34) or high intensity aerobic exercise (active condition, n=34) for 15 minutes on two separate test sessions, with a three-day rest in between. Exercise intensity was determined based on age-related target heart rate (HR) corresponding to 50% and 75% of maximum HR respectively. Following aerobic exercise, participants were immediately assessed for CPM or MIA response, one on each test day, in a random order. A blinded assessor measured pressure pain thresholds (PPT), the main outcome measure, at the elbow and ipsilateral wrist to evaluate CPM and MIA. Data were analysed using linear mixed models, partial correlations, and univariate regression. Results: All participants showed significant increases in PPT at both test sites (p<0.001). The high intensity exercise group demonstrated higher levels of CPM and MIA at both test sites (p<0.001). There were large and positive partial correlations between CPM/MIA and the initial change in PPT following exercise (CPM (r:0.90–0.93, p<0.001)/MIA (r:0.68–0.86, p<0.001)). The change in PPT following aerobic exercise was a significant predictor of both CPM (adjusted R2:92%-95%) and MIA (adjusted R2:73%-93%) response. Conclusion: An acute bout of high intensity aerobic exercise significantly enhanced the analgesic effect of CPM and MIA in people with LE. CPM and MIA may activate similar descending inhibitory mechanisms to mediate their analgesic effects.Trial registration: Prospectively registered with the Australia New Zealand Clinical Trials Registry on 9/02/2017: ACTRN12617000219381, https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372232

Objective: Conditioned pain modulation (CPM) and manipulation-induced analgesia (MIA) are 2 forms of endogenous analgesia. Many forms of analgesia can be influenced by the nature of the patient-clinician interaction. The aim of this study was to evaluate the influence of an empathetic and supportive interaction on CPM and MIA in people with lateral epicondylalgia (LE). Material and Methods: In a double-blind, randomized, controlled trial, 68 participants with LE were assigned to 2 groups: the empathetic and neutral interaction groups. The interactions were carried out by a trained, professional role-play actor, playing the part of a research assistant. The research assistant actor spent 15 minutes before CPM and MIA assessment interacting with the participants in an empathetic or neutral manner. Immediately after the interaction, a blinded assessor measured pressure pain threshold at the symptomatic elbow and ipsilateral wrist during CPM and MIA testing. Linear mixed models were used to evaluate differences in CPM and MIA responses between the interaction groups. Results: There was a significant difference in Consultation and Relational Empathy scores between the groups (P<0.001), indicating that the intervention group experienced a more empathic interaction. Both groups showed a significant increase in pressure pain threshold measures, indicative of a CPM and MIA analgesic response (P<0.001), however, the analgesic responses were greater in the group that had experienced a supportive, empathetic interaction (post CPM, wrist: P<0.001; elbow: P=0.001) (post MIA wrist: P<0.001; elbow: P=0.001). Discussion: A single session of empathetic interaction positively influenced both CPM and MIA responses in people with LE.

Background Shockwave therapy (SWT) is a commonly used intervention for a number of musculoskeletal conditions with varying clinical outcomes. However, the capacity of SWT to influence pathophysiological processes and the morphology of affected tissues remains unclear. The objective of the current review is to evaluate changes in imaging outcomes of musculoskeletal conditions following SWT. Methods A comprehensive search of Medline, Embase, Cochrane Controlled Trials Register, CINAHL and SportDiscus was conducted from inception to October 2018. Prospective clinical trials evaluating the effectiveness of SWT based on changes in imaging outcomes were eligible for inclusion. Articles were evaluated independently for risk of bias using the Cochrane Risk of Bias list and the Methodological Index for Non-Randomized Studies. Random-effects meta-analysis and meta-regression with a priori determined covariates was conducted for each condition to determine potential predictors of SWT effects. Results Sixty-three studies were included, with data from 27 studies available for effect size pooling. Meta-analyses and meta-regression on imaging outcomes were performed for rotator cuff calcific tendinitis ( n = 11), plantar fasciitis ( n = 7) and osteonecrosis of the femoral head ( n = 9). There was an overall reduction in the size of measured lesion following SWT (MD 8.44 mm (95%CI 4.30, 12.57), p < 0.001) for calcium deposit diameter, (MD 0.92 mm (95%CI 0.03, 1.81), p = 0.04) for plantar fascia thickness and (MD 4.84% (95%CI -0.06, 9.75), p = 0.05) for lesion size in femoral head osteonecrosis. Meta-regression showed no influence of SWT dosage parameters, however, baseline lesion size was an independent predictor for changes in imaging outcomes. Conclusions SWT altered the morphology of musculoskeletal conditions, potentially reflecting changes in underlying pathophysiological processes. The parameters of SWT dosage are not significant predictors of changes in imaging outcomes. Lack of adequate reporting of imaging outcomes limited the conclusions that could be drawn from the current review. Registration number: PROSPERO CRD42018091140.

OBJECTIVE:The objective of this study is to determine whether physiotherapy and counselling students, who represent a future generation of two health professions, have differing views about complementary and alternative medicine (CAM).METHODS:In order to determine physiotherapy and counselling students' self-rated knowledge and beliefs about CAM and the factors which influence that understanding, a modified 10-item CAM Health Belief Questionnaire was administered across all year groups to physiotherapy students and counselling students at two universities in Perth, Western Australia. The self-rated paper-based survey measured knowledge of CAM among physiotherapy and counselling students, evaluation of their beliefs regarding the use of CAM, factors that influence their knowledge and beliefs, and their likelihood of recommending CAM to future patients.RESULTS:A response rate of 96.8% was achieved, with 387 physiotherapy students and 88 counselling students. Moderately positive beliefs about CAM were confirmed in both groups, with mean scores of 42.8/70 for physiotherapy students and 43.3/70 for counselling students. There were no significant differences between the student groups in overall self-rated knowledge of CAM. The main factors that influenced the students' responses were personal experience for counselling students and scientific evidence for physiotherapy students. Other factors included university training, attitudes of lecturers, tutors and fellow students, cultural background, and opinions of external practitioners. Counselling students were more likely than physiotherapy students to recommend CAM therapies to their future patients.CONCLUSION:The results from this study demonstrate minimal self-rated knowledge but moderately positive attitudes towards CAM by both physiotherapy and counselling students.

Abstract Background: Stem cell therapy has emerged as a new, exciting treatment for repair of articular cartilage in osteoarthritis (OA), which currently has no cure. Regenerative cell therapies can potentially offer alternatives to total joint replacement for patients with OA. A variety of cell-based therapies have been developed involving the use of autologous and allogeneic mesenchymal stem cells (MSCs). To date, these stem cell therapies have been shown to be safe and efficacious, but information on the long-term clinical outcomes for joint function is lacking. Also lacking is information regarding post-treatment rehabilitation strategies and their effects. Objectives: The purpose of this narrative review was to evaluate the current literature in relation to stem cell therapy for knee OA and to highlight the importance of physical therapists establishing and researching suitable care management and rehabilitation procedures for patients receiving stem cell therapy. Major findings: The results of this literature review show that MSCs have been safe and effective at reducing pain and improving joint functionality and cartilage quality. The review also found that both autologous and allogeneic stem cells were able to produce similar clinical improvements in pain scores and cartilage repair and restoration. There is a lack of research evaluating the influence of rehabilitation on cartilage repair. Conclusions: Current research shows that significant improvements in joint pain and function continue for approximately 2-year post-stem cell procedure. There is currently a lack of research into rehabilitation protocols which could potentially improve joint function further.

We present a phase 1 study that utilizes a crossover design that provides a rapid and relatively inexpensive methodology for evaluating a new transdermal product. The treatment for osteoarthritis (OA) aims to reduce pain and improve function. An innovative magnetophoresis technology has been developed that facilitates transdermal delivery of ibuprofen. The study used measures that were taken over a relatively short time period to monitor the pharmacodynamic response to ibuprofen. Each participant received magnetophoresis-enhanced transdermal ibuprofen or placebo in randomised order, with a five-day washout period. The participants were 24 volunteers with medically diagnosed, painful knee OA. The primary outcome measures were VAS rating of pain on movement and Western Ontario and McMaster Universities (WOMAC) pain and function scores. VAS for pain on movement (p < 0.001), WOMAC pain score (p = 0.004), and WOMAC function score (p = 0.004) were all significantly improved. There was a significant reduction in movement-related pain (p < 0.05) during the first patch application and for the remainder of the study period. The number needed to treat for a 50% reduction in movement related pain was 2.2. The study showed a rapid and significant analgesic effect in response to transdermal ibuprofen. A short trial of this nature can be used for informing the parameters that are required for a major randomised controlled trial.

Objectives: Conditioned pain modulation (CPM) and manipulation-induced analgesia (MIA) may activate similar neurophysiological mechanisms to mediate their analgesic effects. This study assessed the association between CPM and MIA responses in people with lateral epicondylalgia. Materials and Methods: Seventy participants with lateral epicondylalgia were assessed for CPM followed by MIA. A single assessor measured pressure pain thresholds (PPT) before, during, and after cold water immersion (10°C) of the asymptomatic hand and contralateral lateral glide (CLG) mobilization of the neck. For analyses, linear mixed models evaluated differences in CPM and MIA responses. Pearson partial correlations and regression analyses evaluated the association between CPM and MIA PPT. Results: There was a significant increase (CPM and MIA, P<0.001) in PPT from baseline during the interventions (CPM mean: 195.84 kPa for elbow and 201.87 kPa for wrist, MIA mean: 123.01 kPa for elbow and 126.06 kPa for wrist) and after the interventions (CPM mean: 126.06 kPa for elbow, 114.24 kPa for wrist, MIA mean: 123.50 kPa for elbow and 122.16 kPa for wrist). There were also significant moderate and positive partial linear correlations (r: 0.40 to 0.54, P<0.001) between CPM and MIA measures, controlling for baseline measures. Regression analyses showed that CPM PPT was a significant predictor of MIA PPT (P<0.001) and the models explained between 73% and 85% of the variance in MIA PPT. Discussion: This study showed that CPM and MIA responses were significantly correlated and that the CPM response was a significant predictor of MIA response.

Purpose: Cold hyperalgesia is an indicator of widespread pain sensitivity and is associated with poor clinical outcomes. Menthol activates TRPM8, a cold-sensing receptor channel. This research evaluated topical menthol as a potential stimulus to be used in the clinical evaluation of cold hyperalgesia. Methods: Participants were 59 pain free volunteers (17 male: 42 female). A blinded, repeated measures design was used. Participants received applications of menthol at different concentrations in a liquid (study 1) or gel (study 2) formulation with a 24-h interval between each application. Each menthol concentration was applied for 15 min and participants were asked to rate the sensation produced using a series of visual analogue scales and by selecting words from a descriptor list derived from the McGill pain questionnaire (MPQ). The menthol was applied to a site on the volar forearm. Participants also had their cold pain thresholds (CPT) evaluated at the same site using a contact thermode. Results: There were significant concentration-dependent effects for intensity of cold, unpleasantness and pain VAS: cold F-(2 62) = 8.67, p < 0.001; unpleasantness chi(2)((2)) = 14.14, p < 0.001; chi(2)((2)) = 11.74, p = 0.003, with moderate effect sizes for unpleasantness and pain. There were also significant concentration dependent effects for descriptor indices, pain rating index (PRI) F-(2,F-62) = 26.33, p < 0.001; number of words chosen (NWC) F-(2,F-62) = 19.62, p < 0.001, with large effect sizes for 10-20% and 10-30% comparisons. Significant correlations were seen between measures of unpleasantness, pain, PRI, NWC and CPT dependent on menthol concentration. Conclusion: Topical menthol has potential as a stimulus to evaluate cold hyperalgesia.

Objective This pilot study assessed the efficacy of a knee guard device, which used magnetophoresis to transdermally deliver Glucosamine, Chondroitin and Hyaluronic Acid in a cohort of individuals with prior knee injury. The aim was to determine if the change in physical function and pain with the knee guard device was equivalent to the change produced by an established topical NSAID formulation containing diclofenac sodium 1%. Methods A randomized, controlled, equivalence trial evaluated outcomes following treatment with the knee guard device or NSAID formulation. The study recruited 114 male participants (aged 40-55 years). Participants were randomly allocated to wear the knee guard device or to use a NSAID gel daily for two weeks. The primary outcomes were the knee injury osteoarthritis function score (KOOS-F) and an aggregated function score (AFS). The lower extremity functional scale (LEFS), pain numerical rating scale (PNRS), global rating of change (GROC) and other KOOS scores were also evaluated. Results Multiple linear regression analyses indicated that there were no significant differences between the interventions for changes in the primary outcomes of AFS and KOOS_F. The 95% confidence interval (-2.89 to 5.15) of the estimated treatment difference for KOOS-F was within the lower (-5.61) and upper (5.61) bounds of the 7% equivalence margin for that measure, The mean value for the AFS was within, but the 95% CI (-3.11 to 7.37) exceeded the 7% equivalence margin (-2.97 to 2.97) for that measure. There was a significant difference in PNRS, which favored the knee guard device. Conclusion The knee guard device demonstrated equivalence for the KOOS-F measure but not the AFS measure of function over the two week trial period when compared to a widely available NSAID gel that has been shown to be superior to placebo. The knee guard produced a greater reduction in pain report (p = 0.002) than the NSAID gel. Users of the knee guard device experienced more skin irritation than participants using the NSAID gel. Further research is required to fully evaluate the therapeutic potential of this innovative treatment approach.

Background: Stem cell therapy has emerged as a new, exciting treatment for repair of articular cartilage in osteoarthritis (OA), which currently has no cure. Regenerative cell therapies can potentially offer alternatives to total joint replacement for patients with OA. A variety of cell-based therapies have been developed involving the use of autologous and allogeneic mesenchymal stem cells (MSCs). To date, these stem cell therapies have been shown to be safe and efficacious, but information on the long-term clinical outcomes for joint function is lacking. Also lacking is information regarding post-treatment rehabilitation strategies and their effects. Objectives: The purpose of this narrative review was to evaluate the current literature in relation to stem cell therapy for knee OA and to highlight the importance of physical therapists establishing and researching suitable care management and rehabilitation procedures for patients receiving stem cell therapy. Major findings: The results of this literature review show that MSCs have been safe and effective at reducing pain and improving joint functionality and cartilage quality. The review also found that both autologous and allogeneic stem cells were able to produce similar clinical improvements in pain scores and cartilage repair and restoration. There is a lack of research evaluating the influence of rehabilitation on cartilage repair. Conclusions: Current research shows that significant improvements in joint pain and function continue for approximately 2-year post-stem cell procedure. There is currently a lack of research into rehabilitation protocols which could potentially improve joint function further.

Novice students may have limited learning opportunities during their early exposure to complex clinical environments, due to the priorities of patient care. Immersive, high-fidelity simulation provides an opportunity for physiotherapy students to be exposed to relatively complex scenarios in a safe learning environment before transitioning to the clinical setting. The present study evaluated the influence of immersive simulation on student confidence and competence.

Background Complementary and alternative medicine (CAM) is becoming more widely used in the community however there are differences in knowledge and attitudes among and within the various health professions. Chiropractic and nursing students represent a future generation of two health profession groups who may have differing views on CAM. The objectives of this study were to investigate the knowledge, attitudes and beliefs of nursing and chiropractic students about CAM. To investigate the factors that influence their attitudes and beliefs and their likelihood of recommending CAM; and to compare the findings between nursing and chiropractic students to determine similarities and differences. Methods A modified and pre-tested survey including a previously validated 10-item CAM Health Belief Questionnaire (CHBQ) was administered to nursing and chiropractic students at Murdoch University. Student’s demographics were collected as well as other information regarding knowledge, attitudes, influences and use of CAM. Results Three hundred twenty-one nursing and 227 chiropractic students responded with a 91% response rate. The CHBQ overall mean scores for nursing and chiropractic students were 47.6 and 47.4 out of possible 70 respectively, confirming positive attitudes toward CAM in both groups. Nursing and chiropractic students also demonstrated similar knowledge levels. Factors that were most influential in shaping both chiropractic and nursing students’ attitudes and beliefs towards CAM were personal experience and the influence of external peers. Nursing students would not dissuade future patients from CAM, however chiropractic students were more likely to recommend CAM to their future patients. Conclusions Nursing and chiropractic students demonstrate relatively positive attitudes and beliefs towards CAM despite, their limited knowledge concerning CAM modalities generally.

Objectives: Cold hyperalgesia has been established as an important marker of pain severity in a number of conditions. This study aimed to establish the extent to which patients with knee osteoarthritis (OA) demonstrate widespread cold, heat, and pressure hyperalgesia. OA participants with widespread cold hyperalgesia were compared with the remaining OA cohort to determine whether they could be distinguished in terms of hyperalgesia, pain report, pain quality, and physical function. Methods: A total of 80 participants with knee OA and 40 matched healthy, pain-free controls participated. OA participants completed a washout of their usual medication. Quantitative sensory testing was completed at 3 sites using standard methods. Cold pain threshold (CPT) and heat pain thresholds (HPT) were tested using a Peltier thermode and pressure pain thresholds (PPT) using a digital algometer. All participants completed the short-form health survey questionnaire and OA participants completed the PainDETECT, Western Ontario and McMaster Universities Osteoarthritis Index of the Knee (WOMAC), and pain quality assessment scale questionnaires. Results: OA participants demonstrated widespread cold hyperalgesia (P<0.0001), had lower PPT at the index knee (P<0.0001) compared with controls and reported decreased physical health on the SF-36 (P=0.01). The OA subcohort with high global CPT (≥12.25°C) exhibited multimodality sensitization compared with the remaining OA cohort (PPT P<0.0001; CPT P<0.0001; HPT P=0.021 index knee). This group also reported increased pain, decreased function, and more features of neuropathic pain. Discussion: This study identified a specific subgroup of patients with knee OA who exhibited widespread, multimodality hyperalgesia, more pain, more features of neuropathic pain, and greater functional impairment. Identification of patients with this pain phenotype may permit more targeted and effective pain management.

OBJECTIVES:PainDETECT is a self-report questionnaire that can be used to identify features of neuropathic pain. A proportion of patients with knee osteoarthritis (OA) score highly on the PainDETECT questionnaire. This study aimed to determine whether those with a higher "positive neuropathic" score on the PainDETECT questionnaire also had greater pain, hypersensitivity, and reduced function compared with individuals with knee OA with lower PainDETECT scores.MATERIALS AND METHODS:In total, 130 participants with knee OA completed the PainDETECT, Western Ontario and McMaster Universities Arthritis Index (WOMAC), and Pain Quality Assessment Scale questionnaires. Quantitative sensory testing was carried out at 3 sites (both knees and elbow) using standard methods. Cold and heat pain thresholds were tested using a Peltier thermode and pressure pain thresholds using a digital algometer. Physical function was assessed using 3 timed locomotor function tests.RESULTS:In total, 22.3% of participants scored in the "positive neuropathic" category with a further 35.4% in the unclear category. Participants in the "positive neuropathic" category reported higher levels of pain and more impaired function based on the WOMAC questionnaire (P<0.0001). They also exhibited increased levels of hyperalgesia at the knee and upper limb sites for all stimulation modalities except heat pain thresholds at the OA knee. They were also slower to complete 2 of the locomotion tasks.DISCUSSION:This study identified a specific subgroup of people with knee OA who exhibited PainDETECT scores in the "positive neuropathic" category. These individuals experienced increased levels of pain, widespread, multimodality hyperalgesia, and greater functional impairment than the remaining cohort. Identification of OA patients with this pain phenotype may permit more targeted and effective pain management.

Many factors interact to influence threat perception and the subsequent experience of pain. This study investigated the effect of observing pain (extrinsic threat) and intrinsic threat of pain to oneself on pressure pain threshold (PPT). Forty socially connected pairs of healthy volunteers were threat-primed and randomly allocated to experimental or control roles. An experimental pain modulation paradigm was applied, with non-nociceptive threat cues used as conditioning stimuli. In substudy 1, the extrinsic threat to the experimental participant was observation of the control partner in pain. The control participant underwent hand immersion in noxious and non-noxious water baths in randomized order. Change in the observing participant's PPT from baseline to mid- and postimmersion was calculated. A significant interaction was found for PPT between conditions and test time (F-2,F-78 = 24.9, P < .005). PPT increased by 23.6% +/- 19.3% between baseline and during hand immersion (F-1,F-39 = 43.7, P < .005). Substudy 2 investigated threat of imminent pain to self. After a 15-minute break, the experimental participant's PPT was retested ("baseline 2"). Threat was primed by suggestion of whole arm immersion in an icier, larger water bath. PPT was tested immediately before anticipated arm immersion, after which the experiment ended. A significant increase in PPT between "baseline 2" and "pre-immersion" was seen (t = -7.6, P =.005), a pain modulatory effect of 25.8 +/- 20.7%. Extrinsic and intrinsic threat of pain, in the absence of any afferent input therefore influences pain modulation. This may need to be considered in studies that use noxious afferent input with populations who show dysfunctional pain modulation. Perspective: The effect on endogenous analgesia of observing another's pain and of threat of pain to oneself was investigated. Extrinsic as well as intrinsic threat cues, in the absence of any afferent input, increased pain thresholds, suggesting that mere threat of pain may initiate analgesic effects in traditional noxious experimental paradigms. (C) 2017 by the American Pain Society