Much of my early professional years were spent watching competitive sports. After 1-2 years in general practice I was hired by Tulane University in New Orleans, Louisiana, as Assistant Athletic Trainer. Tulane University competed in Division I Athletics which meant that a majority of their student athletes attended on a ‘full-ride’ scholarship; our ability to keep them healthy was taken quite seriously.
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Inaugural lecture Enrique Lluch Girbes as visiting professor at the Vrije Universiteit Brussel: ‘Osteoarthritis pain: understanding pain mechanisms & combining pain neuroscience education with Mulligan manual therapy’.
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In low back pain there are clear clinical differences seen between recurrent and chronic low back pain patients.
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When patients with chronic back pain present with poor body awareness, high stress levels, catastrophic thinking and fear-avoidance behaviors, physical therapists need biopsychosocial treatment interventions in addition to standard practices based on structural impairment to achieve pain relief and functional improvement.
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Neurodynamics or neural mobilisation is an intervention aimed at restoring the altered homeostasis in and around the nervous system (Coppieters and Nee 2015).
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A universally accepted term for the phenomenon ‘central sensitization’ in humans is not available yet and a proof of this fact is that its use in scientific literature is still under debate (Kosek et al. 2016).
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This is a question most clinicians dealing with people in pain must have asked themselves many times before. We have too.
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Resilience in the face of pain   October 31st, 2017
Readers of this blogpost are all aware of the huge impact that chronic pain has on both personal lives and society as a whole. The numbers speak for themselves and point to the urgent need for improvements in the ways we conceptualize pain in our theoretical frameworks and how this works out in clinical practice.
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The effect of exercise therapy has been extensively studied in health and disease. While it is broadly agreed that a program of exercises is beneficial, the same cannot be said for a single session. Symptoms worsening following exercise is indeed a common feature in people with chronic pain.
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In Belgium, every year, nearly 75.000 patients are diagnosed with cancer. That’s 205 patients a day, 9 patients an hour.
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I bet you all know someone in your close environment – a friend, family member, workmate - who suffers from chronic pain. Maybe chronic pain even controls your own life from time to time? Let me reassure you, you’re not the only one.
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Excepcional calidad de España   August 25th, 2017
Friday, July 14, 2017 in the beautiful Aulario V, Faculty of Physiotherapy of the University of Valencia (Spain): Enrique Lluch Girbés is defending his PhD in front of an international jury of experts.
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Similar as in adults, children’s pain experience occurs within a complex biopsychosocial framework. However, the presence of specific factors and their relative share in contributing to the development and maintenance of pain in children are distinct from those in adults.
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Objectively classifying and diagnosing different pain conditions remains a challenge for scientific research and clinical practice. Currently, self-report measures of pain and psychosocial factors are considered the gold standard for pain measurement and these measures perform well.
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Since the Cartesian model and the understanding of ‘a nervous system’, there has been a dualistic approach of pain. Especially in Western societies, a strong focus on ‘the bodily part’ of pain still exists today, as many (Western) healthcare professionals are of the opinion that pain needs a bodily onset.
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Unravelling low back pain remains a clinical challenge and the ideas about what can count as proper and necessary judgements are still a topic for debate.
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​Recently, Dorien Goubert and Iris Coppieters obtained their PhD degree at Ghent University, Belgium. Dorien completed her PhD on studies linking peripheral (i.e., muscular) and central aspects of chronic low back pain. The title of her PhD was ‘Peripheral back muscle dysfunctions and central pain mechanisms: an innovative perspective on differences between recurrent and chronic pain’ and you can check out her publications here: https://www.ncbi.nlm.nih.gov/pubmed/?term=Goubert+D%5BAuthor%5D). Iris’ PhD, entitled ‘Relationships between cognitive deficits, central sensitization, and structural brain alterations in patients with chronic idiopathic neck pain, chronic whiplash associated disorders and fibromyalgia. Unravelling differences in underlying mechanisms’ included some of her following publications: https://www.ncbi.nlm.nih.gov/pubmed?term=Coppieters%20I%5BAuthor%5D&cauthor=true&cauthor_uid=24508406 Congratulations to both of them!
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Pain has always been a matter of interest to those involved in rehabilitation and medicine. Decades of research has led to the understanding that pain is an extensive and complex mechanism, influenced by thoughts, emotions, context, previous experiences, perceptions, etc.
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Working in a rehabilitation centre means that you have to deal with pain every day. Actually, it is quite frank to notice that someone’s pain is an everyday part of my job.
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Within the biomedical model, pain is considered a consequence of tissue damage. However, we all know now that a precise biomedical diagnosis cannot be given in the majority of the low back pain (LBP) patients. Enter: the biopsychosocial perspective.
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Musculoskeletal pain is a highly prevalent disorder. People often seek help from a physiotherapist to relieve their pain and related limitations.
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Patient’s pain and disability improvement is an everyday challenge for physiotherapists.
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For centuries chronic pain has been viewed as a solely biomedical issue in the tissues. However, times are changing and we now know that (chronic) pain is a complex construct in which not only physiological factors play a role. In addition, pain is influenced by psychological factors, such as thoughts and feelings, and social factors, for instance judgement and misunderstanding.
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The biomedical model falls short in explaining chronic pain. Although many clinicians have moved on in their thinking and apply a broad biopsychosocial view with regard to chronic pain (patients), the majority of clinicians (including myself) have received a biomedical-focused (undergraduate) training/education.
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It is well established that pain has the function of maintaining the integrity of the body. Pain is an evolutionarily acquired alarm signal of bodily threat and this phylogenetic function is extremely important for survival.
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Are athletes special people?   November 28th, 2016
Of course they are. We all have witnessed them and their exceptional performances during last summers’ Olympic games, the once-every-four-year alibi for sports fanatics to avoid bodily movement while watching their favourites giving the best of themselves.
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On the 5th of July, Dr Isabel Baert, Dr Enrique Lluch en Dr Mira Meeus, all Pain in Motion members, will give a post-congress course at the World Congress of Physiotherapy (WCPT), together with Dr Ina Diener, from Stellenbosch University and University of the Western Cape.
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On October 3rd 2016 a (Dutch) blog post was published on our website concerning a study comparing ‘back school’ and ‘brain school’ in patients undergoing surgery for lumbar radiculopathy, titled “Rugschool of pijneducatie bij chirurgie voor lage rug- en beenpijn”.
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Temporomandibular Disorders (TMD) and orofacial pain are conditions that have been drawing more attention from Physical Therapists (PTs) in the recent years.
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What you see is what you get?   November 24th, 2016
What you see is what you get, no? Not for whiplash patients!
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Lage rugpijn blijft één van de duurste en meest invaliderende problemen van onze Westerse samenleving. Logisch dus dat voor vele stakeholders (patiënten, paramedici, artsen, firma’s en overheden) de focus hierop ligt.
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In Belgium nearly every hospital has a specialized pain center to treat patients with chronic and/or debilitating pain. These pain centers developed and evolved over the years and became multidisciplinary teams.
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Het Expertisecentrum Pijn en Revalidatie, waarin Adelante en MUMC+ samenwerken op het gebied van chronische pijn, streeft naar toegankelijke revalidatiezorg bij chronische pijn voor zeer complexe en minder complexe problematiek. Hiervoor lanceert zij het Netwerk Pijnrevalidatie Limburg.
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Margot De Kooning, PhD candidate   October 4th, 2016
(August 30, 2016) 7:15 pm: The moment Margot De Kooning got rewarded for five years of hard work, by being promoted to ‘Doctor in Rehabilitation Sciences and Physiotherapy’.
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Jaarlijks worden enkele duizenden patiënten geopereerd voor lage rugpijn met uitstraling naar het been (lumbale radiculopathie). Onderzoek wijst uit dat 23-28% postoperatief chronische pijn zullen ontwikkelen.
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In this blogpost, the most important elements of this systematic review and meta-analysis are highlighted.
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Shoulder complaints are common in physiotherapy practice and consist of pain and functional limitations.
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A wide range of human brain imaging techniques has provided the opportunity to explore in vivo the neurophysiological processes of the brain. This neuroimaging research has shown neuronal plasticity, which refers to the possibility of the central nervous system including the brain to adapt but also to maladapt structure, function and organization.
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Chronic fatigue syndrome (CFS) is a complex syndrome with severe and debilitating fatigue. The experienced fatigue is not sufficiently reduced by resting, causing patients to perform less occupational, educational, social or personal activities and consequently restricting their participation.
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Margot De Kooning will present her PhD in public on Tuesday 30 August 2016 at the Vrije Universiteit Brussel, Brussels Health Campus (Jette).
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The current definition of central sensitisation (CS) pain describes CS as manifesting in a generalised hyper-sensitivity of the somatosensory system.
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Pain neuroscience has taught us that pain can be present without tissue damage, is often disproportionate to tissue damage, and that tissue damage (and nociception) does not necessarily result in the feeling of pain.
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The scapula plays an important role in the function of the shoulder. During humeral elevation of the arm, a complex scapular movement of upward rotation, posterior tilt and external rotation is needed to create a stable base for the glenohumeral joint.
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Knee osteoarthritis (OA) is predominately characterized by knee pain, which can lead to impaired physical function and decreased quality of life
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Traditionally the clinical manifestation of entrapment neuropathies (e.g., carpal tunnel syndrome, cervical and lumbar radiculopathy) is considered to be driven by local mechanisms and signs and symptoms should follow a clear anatomical pattern limited to the structures innervated by the affected peripheral nerve, or restricted to the corresponding dermatome, myotome and sclerotome.
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In the new edition of ‘Pain: Clinical Updates’ we published in connection with the ‘2016 IASP Global Year Against Pain in the Joints’ an overview paper to help clinicians prescribing/developing exercise programs for patients with chronic joint pain.
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​One important aspect of dealing with patients with central pain syndromes is that no two patients are the same. Patients with persistent pain differ in their complaints and pain characteristics. Besides their pain related symptomatology, also their coping-style is different.
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Many patients with chronic pain suffer from stress intolerance, and some patients have developed chronic pain during or following a stressful period or (life) event (e.g. motor vehicle accident, trauma exposure). When chronic pain is present, stress typically worsens the pain (severity). Taken together, stress and chronic pain are closely connected. In this blog post fascinating research findings regarding the effect of chronic stress on the brain are presented, providing a neuroscientific explanation why chronic stress may lead to the development of chronic pain.
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I once was told by a former colleague that I would most definitely get back pain if I didn’t stop slumping in my L1 vertebra. Of course today I am still ‘slumping in my L1 vertebra’ and no, I don’t believe that it will ever cause me back pain.
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The prevalence of chronic sports injuries is high, while the etiology and pathophysiological mechanisms have largely remained unknown. To date, the most commonly used approach is limited to a biomedical one, focused on abnormalities and inflammation.
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The role of the periaqueductal gray (PAG) has been described in many studies regarding pain processing. This structure, located in the midbrain around the cerebral aqueduct, is mainly known as a key region in descending pain modulation.
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Recently, I finished my PhD on Fisioterapia Manual at the University of Alcalá (Madrid, Spain). This PhD comprises five manuscripts related to neck pain, cervical movement control dysfunction and the influence of scapula on neck pain.
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Manchikanti and colleagues (2011) make in their paper entitled ‘placebo and nocebo in interventional pain management: a friend or a foe – or simply foes?’ an argument for a revaluation of placebo effects in clinical practice. They make the claim that clinicians should not try to avoid the placebo effect, but should try to potentiate it, as this effect isn’t just unethical and mythical but must seen as a very real phenomenon, which can be understood from a vast body of both psychological and neurophysiological research.
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​There is wide international consensus on the need of having agreed and standardised sets of outcomes, better known as ‘core outcome sets’ (COSs). A COS represents the minimum that should be measured and reported in all clinical trials for a specific health condition, and that can also be suitable for use in other types of studies or clinical practice.
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Chronic back pain (CBP) is an important clinical, social, economic, and public health problem. Many risk factors are associated with CBP. However, the evidence is often cross-sectional. In an innovative study, researchers from the Northwestern University of Chicago explored the relationship between smoking, transition to chronic pain and functional characteristics of the brain.
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Conventional rehabilitation for people with chronic pain is often unsuccessful and frustrating for clinicians. What it is becoming clear more and more is that new therapeutic approaches are needed in view of current understanding of neural mechanisms underpinning chronic pain. In this regard, three papers aiming to summarize the role of central sensitization in chronic musculoskeletal pain and looking for guide clinicians in the rehabilitation of patients with chronic pain have been recently published.
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​Pain is the number one reason for patients visiting a physiotherapist. Chronic pain is the most costly condition affecting the Western world. This comes as no surprise: pain is omniprevalent among a wide variety of medical disciplines, ranging from oncology, pediatrics, geriatrics, rheumatology, orthopedics, neurology and internal medicine. For reducing the costs associated with chronic pain, correct mechanism-based classification of the pain type is the first step.
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​Postmenopausal women with hormone receptor-positive breast cancer receive hormone therapy as part of their cancer treatment. One of the most frequently used and evidence-based hormone treatments are aromatase inhibitors (= inhibitors of the enzyme aromatase) that inhibit the conversion of androgens to estrogens. This results in decreased availability of estrogens and slowed progression of breast cancer.
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​Remembering an event reactivates at least part of the cortical and subcortical regions that were engaged during the original experience of that event. This is termed “reinstatement” of brain activity during memory retrieval. German and UK researchers have conducted a fascinating study showing reinstatement of pain-related brain activation during viewing of neural images that had previously been paired with heat pain.
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​Scapular dyskinesia has been widely accepted in the literature as associated with glenohumeral joint pathology. Clinicians who manage patients with shoulder pain need to have the skills to assess static and dynamic scapular positioning. At this point, clinicians can use reliable (and valid) clinical tests for the assessment of both static and dynamic scapular positioning in patients with shoulder pain.
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​People with chronic fatigue syndrome (CFS) may be limited in activity performance and role fulfilment to a large extent. A lot of them enter a vicious circle of inactivity, leading to increased levels of fatigue. It is therefore important to break this negative process. One of the approaches is to facilitate people with CFS in self-managing their daily activity levels.
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​Some months ago I came across a novel study by Harvie and colleagues (2015); they used virtual reality to investigate the effect of overstated or understated visual information on cervical rotation in patients with neck pain. This empirical study shows that we might need to reconsider how we interpret diagnostic provocation tests in daily care, e.g. that it is not a solid measurement for primary nociceptive information or tissue provocation.
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​In a very recent review and clinical guideline of Heather Kroll, a nice overview is given about how exercise affects pain. But besides listing possible mechanisms of exercise induced analgesia, she reviews the therapeutic modalities and benefits for a wide variety of chronic pain diagnoses.
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​Several studies demonstrated the importance of assessing the perceptions of patients regarding their illness (i.e. the illness perceptions) as they are of prognostic value.
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​Even though a total knee replacement is an effective surgical treatment for end-stage knee osteoarthritis and the majority of patients report significant pain relief and functional improvement post-surgical, literature shows that up to 20% of patients undergoing a total knee replacement are dissatisfied and complain of persisting pain, functional disability and poor QoL ( Scott et al. 2010).
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Hoe denkt u over pijn?   January 1st, 2015
​In juli 2015 heeft retrain pain een educatieve tool gelanceerd die u als professional kan ondersteunen bij het geven van pijneducatie aan uw patiënten.Sindsdien zijn wij bezig geweest met de Nederlandse vertaling. Wij zijn enthousiast om te kunnen melden dat deze af is!​
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​During the last decade there has been much discussion about pain and its manifestations, their presence and, naturally, their absence. As physiotherapists and health care professionals we have taken tools from other disciplines to advance in our own; we adopted neuroscience (for understanding the functioning of our nervous system) and philosophy (for understanding how the mind works). In theory everything is clear to us, but in reality our knowledge does not always correlate with clinical outcomes.
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​This is short case study with observations from the clinic which may raise interesting research questions.
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​Osteoarthritis (OA) of the knee has long time been considered as a structural pathology with a clear nociceptive explanation, resulting from joint degeneration. Nevertheless, recently awareness is growing for the involvement of the central nervous system in the amplification of pain in OA. This may explain why many patients still suffer chronic pain after surgery, long time after removal of the source of nociception.
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​In November 2015 a short summary of our review in Manual Therapy (Leysen et al. 2015) will be published in FysioPraxis (Fysiopraxis Nov. 2015, p39), the monthly magazine of physiotherapy in the Netherlands.
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​Chronic musculoskeletal pain is a complex problem and has significant psychological, physical, social and economic implications. There is inevitable pressure for hospitals to reduce waiting times and improve treatment outcomes. Given the significant burden upon the individual, society and the economy, it is important to identify more effective management strategies.
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The awareness is growing that neurotrophic factors, like brain-derived neurotrophic factor (BDNF), have a cardinal role in initiating and/or sustaining the hyperexcitability of central neurons in chronic pain patients. For example, microglial-derived BDNF contributes significantly to neuropathic pain. Therefore, potential pharmacological or conservative (e.g. exercise) treatment of neurotrophic factors like BDNF provides important new treatment avenues.
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​Osteoarthritis (OA) is traditionally considered a progressive disorder of articular cartilage in the joint, yet increasing evidence suggests that at least in an important subgroup of patients with OA the clinical picture is dominated by sensitization of central nervous system pain pathways (i.e. central sensitization) rather than by structural dysfunctions causing nociceptive pain (reviewed by Lluch et al. 2013).
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Trait anxiety is an enduring (i.e. relatively stable) personality trait, or characteristic, indicative of differences in an individual's proneness to reactions of state anxiety when faced with a perceived psychological threat. (Compare this with state anxiety which is transient, in the present.)
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Clinically it is important to distinguish between the three main pain mechanisms that may present with our patients experiencing chronic pain (Nijs et al 2014). Here I describe my clinical findings in two chronic low back pain patients, one with chronic nociceptive pain and the other with chronic central pain mechanisms.
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Het chronische vermoeidheidssyndroom (CVS) is een erg onderschatte en nog te weinig bestudeerde aandoening. Naar schatting treft CVS 0.5 tot 2.5% van de bevolking. De aandoening gaat gepaard met een zeer hoge medische, economische en sociale kost. Experts van vijf Belgische universiteiten trekken met een open brief aan de alarmbel.
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The concept of myofascial trigger points keeps on inspiring researchers and clinicians. With the recent publication of an interesting review article in Rheumatology, the concept is really challenged.
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Research has suggested that exercise is effective in the treatment of chronic low back pain (CLBP), regardless the characteristics of the exercise selected. Although it’s effective, exercise as intervention alone does not seem to take into consideration the maladaptive pain cognitions and illness behavioural characteristics frequently identified in CLBP patients.
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A new fascinating study from the Harvard Medical School (Boston, U.S.A.) adds to the evidence that conservative interventions can retrain the brain (ref. 1). Laura Simons and her colleagues reported marked differences in functional brain connectivity between pediatric complex regional pain syndrome patients and age-sex matched control subjects, but also normalization of such differences following in-house rehabilitation.
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There is strong evidence that patients with chronic pain show decreased cognitive task performance, including decreased sustained selective attention, processing speed and memory. Pain in Motion recently reported on Kelly Ickmans’ PhD findings, showing that in patients with various central sensitization pain disorders (fibromyalgia, chronic whiplash associated disorders, chronic fatigue syndrome), cognitive performance is closely related to physical activity levels and endogenous analgesia.
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The internet is nowadays a popular information source for the general public when it comes to medical advice. It is an easy to use and very cheap source of information, which may lead to less medical consults. On the other hand, it can have several negative effects, like an overload of information, increased anxiety, distress, and compulsive search for medical information. Recently, this phenomenon has been referred to as “Cyberchondria”.
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Hyperexcitability of the central nervous system, or central sensitization, is considered to be a maladaptive type of neuroplasticity often seen in patients with chronic pain. Central sensitization is frequently seen in patients with osteoarthritis, fibromyalgia, whiplash, neuropathic pain and chronic fatigue syndrome. Up to recently, shoulder pain was considered to be a pure ‘local’ problem. Tissues that are frequently linked to shoulder pain include (rotator cuff) muscles, ligaments, subacromial bursa and joint capsules.
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Therapeutic pain neuroscience education (TPNE) is becoming increasingly popular as (part of) the treatment of (chronic) pain and aims at altering the patient’s thoughts and beliefs about pain. Previous research has demonstrated the efficacy of TPNE in the treatment of chronic pain. TPNE is mostly given in one-on-one sessions, which has limitations, as it is time intensive, cost intensive and limited to patients in remote areas. Pain in Motion previously showed that written TPNE does little to alter pain, pain cognitions or illness perceptions in patients with fibromyalgia.
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Interpreting scientific results in clinical practice can be, to say at least, challenging. Especially when it is somewhat contradictory to what you have heard during all those years of extensive training in both physiotherapy education and other courses. As one of my friends recently put it this way: ‘The more I learn about pain, the less I know and the more confused I get.’
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Fysiopraxis Themanummer Pijn   January 1st, 2014
Het vaktijdschrift voor fysiotherapeuten in Nederland, Fysiopraxis, heeft in een themanummer over pijn aandacht besteed aan pijn in alle vormen. Hierbij zijn vele experts op het gebied van (chronische) pijn benaderd. Vanuit de onderzoeksgroep Pain in Motion zijn er meerdere onderzoekers betrokken geweest bij dit themanummer. Zo is Jo Nijs aan het woord over waarom juist pijn een indicatie is om te behandelen.
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Persistent pain in the absence of structural pathology remains a challenging issue for clinicians. Besides the suffering from the pain itself, chronic ‘unexplained’ pain is often accompanied by other debilitating symptoms such as fatigue, sleep difficulties, dizziness, psychological symptoms, and cognitive problems among others. A growing body of scientific research underlines the involvement of a common pathophysiological mechanism of central sensitization (CS), commonly known as an hypersensitivity of the central nervous system, in overlapping chronic pain conditions such as chronic fatigue syndrome (CFS), fibromyalgia (FM) and chronic whiplash-associated disorders (WAD).
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A recent article by Lance M. Mc Cracken and Stephen Morley published in the Journal of Pain addresses the place of theory and models in psychological research and treatment development in chronic pain. It argued that such models are not merely an academic issue but are highly practical. Such models ought to integrate current findings, precisely guide research and treatment development, and create progress. The dominant psychological approach to chronic pain is cognitive behavioural therapy (CBT).
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The study by Schabrun et al. published in Brain Stimulation 2014 is one of the most interesting papers I have read last year. This might be due to the fact that I am not at all an expert in neuromodulation, but even so the study is highly innovative and has amazing findings. The paper reports a placebo-controlled cross-over study investigating the effect of transcranial direct current stimulation (tDCS) combined with peripheral electrical stimulation (PES) treatment on pain, cortical organization, sensitization and sensory function in 16 patients with chronic low back pain. It was found that a combined tDCS/PES intervention is more effective for improving not only chronic low back pain symptoms, but also for improving the mechanisms of cortical organization and central sensitization than either intervention applied alone or a sham control.
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Stress is often a powerful pain killer. Stress activates several brain-orchestrated pain inhibitory actions, including the activation of the hypothalamus-pituitary-adrenal axis (HPA-axis) resulting in the release of cortisol. The latter is often regarded as the major stress hormone in the human body, and besides its powerful anti-inflammatory action it also exerts endogenous analgesia.
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Based on a literature study on the effects of relaxation on symptoms and daily functioning in patients with FM, the authors concluded that:
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A systematic literature review recently showed that approximately 30% of patients with osteoarthritis have central sensitization pain, implying that their pain is dominated by central factors (i.e. the increased hyperexcitability of the central nervous system) rather than peripheral (i.e. joint) factors.
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In 2011, Pain in Motion published a paper explaining to clinicians the various options we have for treating the mechanisms involved in central sensitization.
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The April issue of Pain reports a sound study examining self-perceived pain changes during walking in patients with osteoarthritis. Pain in Motion previously reported that up to 30% of osteoarthritis patients have central sensitization, and this new study from U.S. researchers suggests a role for central sensitization in explaining pain changes during daily physical activities like walking
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Chronic Fatigue Syndrome (CFS), or myalgic encephalomyeltitis (ME), is a severe and underestimated illness. The presence of symptoms like a sore throat, tender lymph nodes, and low-grade fever, as well as flu-like symptoms including widespread muscle pain and severe fatigue, has inspired researchers to search for immune abnormalities in patients with ME/CFS.
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Even though nociceptive pathology has often long subsided, the brain of patients with chronic musculoskeletal pain has typically acquired a protective (movement-related) pain memory. Exercise therapy for patients with chronic musculoskeletal pain is often hampered by such pain memories.
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Why does my shoulder hurt?   January 1st, 2014
Dean et al. recently reviewed the neuroanatomical and biochemical basis of shoulder pain. Shoulder pain is often a very challenging clinical phenomenon because of the potential mismatch between pathology and the perception of pain. As shoulder pain is very common in the physiotherapeutic clinical practice, a vast understanding of pain processing could enlarge the specificity of the patients’ diagnosis and steer treatment.
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The prevalence of tendinopathies is high both in athletes and in the general population. Despite a wealth of literature, the pain mechanisms of tendinopathies are not well understood. Currently, some studies have described whether, or to which degree, somatosensory changes within the nervous system may contribute to the pain in tendinopathies.
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