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The Musculoskeletal Wrangler, Wonthaggi (2025)

31/07/2025

Neuropathic pain: a maladaptive response of the nervous system
Part 2: future challenges and issues
📍An editorial paper by Costigan et al. (2009) provide a review of the neurobiological mechanisms of neuropathic pain, and explain the clinical challenges and future issues we face when trying to understand the neuropathic pain phenotypes.
CHALLENGES:
⚠️Animal surrogate models lack complexity. They do not provide accurate insights into neuropathic pain processing, and subjective symptoms cannot be evaluated.
⚠️Electrophysiological investigations such as QST, NCS, SEPs/MEPs reveal information on the function of nerve fibers, but do not provide insight into the cellular and molecular processes responsible for pain.
⚠️fMRI reveals abnormal processing of sensory input, but is generally limited to research studies only.
⚠️Skin biopsies document sensory fiber loss, however they are invasive and not suitable for routine use in clinical practice.
⚠️Diagnostic labels for neuropathic pain conditions are usually base on pathoanatomy, not pathophysiology, making it difficult to discern the mechanisms responsible.
FUTURE ISSUES (see image):
FUTURE DIRECTIONS:
⛔️A standardised and comprehensive classification of pain phenotypes may provide the next best approach to capture relevant information that may directly reflect pain mechanisms; a critical step in developing a successful targeted approach to pain management.
MW
Reference:
Costigan M, Scholz J, Woolf CJ. Neuropathic pain: a maladaptive response of the nervous system to damage. Annual Review of Neuroscience,2009;32:1-32.

31/07/2025

Neuropathic pain: a maladaptive response of the nervous system
Part 1: aetiology & pathophysiology
📍An editorial paper by Costigan et al. (2009) provide a review of the neurobiological mechanisms of neuropathic pain, which operate across multiple sites within the somatosensory nervous system.
AETIOLOGY:
🔎Peripheral neuropathic pain results from a lesion to the peripheral nervous system (PNS), often caused by mechanical trauma, metabolic disease, neurotoxic chemicals, infection, tumour invasion or other such mechanisms. Central neuropathic pain most commonly results from spinal cord injury, stroke, MS or other such CNS lesions.
PATHOPHYSIOLOGY:
Neuropathic pain involves multiple pathophysiological changes within the PNS and CNS, incl:
🔆Ectopic impulse generation
🔆Ectopic transduction
🔆Central sensitisation
🔆Low threshold A-beta fiber-mediated pain
🔆Disinhibition (of endogenous inhibitory transmission)
🔆Structural changes incl. peripheral sprouting following axonal injury
🔆Neurodegeneration
🔆Neuro-immune interactions
CONCLUSIONS:
⚠️Neuropathic pain can originate through various aetiological mechanisms across the PNS and CNS, and via multiple pathophysiological mechanisms including genetic, cellular and molecular domains.
MW
Reference:
Costigan M, Scholz J, Woolf CJ. Neuropathic pain: a maladaptive response of the nervous system to damage. Annual Review of Neuroscience,2009;32:1-32.

29/07/2025

Multidisciplinary assessment of patients with chronic pain
Part B: Psychological interview
📍A chapter by Turk & Robinson (2019) outline the principles underpinning the multidisciplinary assessment of patients with chronic pain. Detailed below is a conceptual framework of their psychological interview:
EXPERIENCES OF PAIN
🔎Pain location, descriptors, severity
Onset and progression
🔎Perception of cause and current beliefs, thoughts, feelings & behaviours
🔎Symptomatology – pattern, exacerbating & relieving factors
Sleep habits
PAST TREATMENTS:
🔎Medications, incl. effectiveness? Pattern of use?
🔎Physical therapies? Exercise? Complementary treatments?
COMPENSATION & LITIGATION:
🔎Current disability status? Pending litigation?
PAIN RESPONSE & COPING:
🔎Daily routine? Life stressors?
🔎Changes in activities and responsibilities?
🔎Self-efficacy during flare ups? Impact on relations?
🔎Coping strategies, incl. avoidance or pacing?
EDUCATIONAL, VOCATIONAL & SOCIAL HISTORY
🔎Level of education? Work status/history? Relationships and support?
ALCOHOL & SUBSTANCE USE:
🔎History and current? Dependence?

PSYCHOLOGICAL DYSFUNCTION:
🔎Personal & familial history psychiatric disorders or symptoms?
CONCERNS & EXPECTATIONS:
🔎Treatment expectations, prognosis and attitude?
MW
Reference:
Turk DC, Robinson JP. Psychological approaches. In: Ballantyne JC, Fishman SM, Rathmell JP, editors. Bonica’s management of pain. 5th ed. Philadelphia: Wolters Kluwer Health; 2019. p. 313–27.

29/07/2025

Multidisciplinary assessment of patients with chronic pain
Part A: Brief psychosocial screening
📍A chapter by Turk & Robinson (2019) outline the principles underpinning the multidisciplinary assessment of patients with chronic pain. Detailed below is their conceptual assessment framework:
Assessment of Medical factors:
🔆Can we formulate a biomedical diagnosis? Is diagnostic testing required? Are there red flags? Are there risk factors for delayed recovery?
Specific evaluation procedures:
🔆History, physical examination, ancillary studies?
Assessment of CNS sensitisation:
🔆QST? Conditioned pain modulation (CPM)? fMRI?
Assessment of psychosocial factors:
🔆Causal agents, contributors or consequences of pain?
🔆Brief psychosocial screening (see image)
🔆Psychological interview (see next post)
🔆Social factors?
Assessment of pain:
🔆Intensity? Quality? Modifiers? Overt expressions? Emotional distress & fear? Beliefs, coping & psychosocial adaptations?
Assessment of functional impact:
🔆Self-report measures? Physical capacity?
CONCLUSION:
🔆The assessment of chronic pain should encapsulate the multidimensional, influential factors that can modulate the pain experience and associated disability, including CNS processing, psychosocial, environmental and behavioural factors.
MW
Reference:
Turk DC, Robinson JP. Psychological approaches. In: Ballantyne JC, Fishman SM, Rathmell JP, editors. Bonica’s management of pain. 5th ed. Philadelphia: Wolters Kluwer Health; 2019. p. 313–27.

29/07/2025

Diagnostic blocks
📍A chapter by anaesthesiologists, Stogicza and Peng (2022) outline the purpose for, and practices of interventional procedures such a diagnostic blocks in the context of pain.
OVERVIEW:
🔎Interventional procedures are non-surgical minimally-invasive techniques commonly used in the assessment, diagnosis and management of pain.
PURPOSE:
🔆The two main roles of a diagnostic block in pain management is to locate the source of symptoms, and to prognosticate one’s likely treatment response to said intervention.
INTERPRETATION:
📈A positive response confirms the source of pain (true positive)
📉A negative response generally suggests the source of pain is NOT from the targeted structure (true negative).
⚠️Both positive and negative responses however, can be influenced by higher centres of the CNS as a result of expectation or contextual effects (false positive/negative).
PERCUTANEOUS INTERVENTIONAL PROCEDURES (see image)
CONCLUSIONS:
🔆Clinicians need to make an assumption that the diagnostic block accurately disrupts the “pain pathway”, though this is not always the case. Both, positive and negative responses can be influenced by higher centres of the CNS as a result of expectation or contextual effects, and clinicians need to be aware of these limitations!
MW
Reference:
Stogizca A, Peng PW. Diagnostic and therapeutic blocks. In: Lynch ME, Craig KD, Peng PW, editors. Clinical pain management: a practical guide. 2nd ed. Hoboken (NJ): Wiley Blackwell; 2022. Chapter 22. Available from: https://doi.org/10.1002/9781119701170.ch22

29/07/2025

Fibromyalgia syndrome (FMS)
An update
📍A paper by Galvez-Sanchez & Rayes del Paso (2020) provided a critical review of the literature underpinning the diagnostic criteria for fibromyalgia.
DEFINITION:
🔎FMS is a chronic disorder characterised by widespread and persistent non-inflammatory musculoskeletal pain leading to impaired health-related quality of life. Concomitant symptoms usually include hyperalgesia, allodynia, fatigue, insomnia, morning stiffness, negative affect (depression, anxiety etc) and cognitive impairments (concentration difficulties, mental slowness, memory and attention problems).
PREVALENCE:
🔆It is estimated to affect 2-4% of the general population.
AETIOLOGY, PATHOPHYSIOLOGY & RISK FACTORS:
🔆The aetiology of FMS remains unknown. The most well-supported hypotheses regarding its pathophysiology is the presence of central sensitisation (ie: altered endogenous pain inhibitory mechanisms). Some factors are known to predispose individuals to FMS including, genetic, as well as adverse life events (eg: trauma).
SEVERITY:
“🔆Central sensitivity score” (FKA “fibromyalgia severity scale”) is an established method used to classify one’s FMS severity. It is computed as the sum of “widespread pain index (WPI)” and the “symptom severity (SS) scale”. Each of these clinical measures encapsulate the number and severity of symptoms across multiple body regions.
DIAGNOSTIC CRITERIA (Image derived from: Marfarlane et al. 2016)
🔆WPI: 14 or more AND SS: 7 or more are considered important diagnostic criteria for FMS. The subjective nature of symptoms coupled with the absence of a gold standard makes the diagnostic process difficult and contentious. A significant proportion of patients who do not fulfil the diagnostic criteria are nevertheless severely affected.
CONCLUSIONS:
⚠️FMS is a multi-symptom and multi-system syndrome that can be considered along a continuum from mild to severe.
MW
Reference:
Galvez-Sanchez CM & Reyes del Paso GA. Diagnostic criteria for fibromyalgia: critical review and future perspectives. Journal of Clinical Medicine,2020;9(1219).
Macfarlane GJ, Kronisch C, Dean LE, Atezeni F, Hauser W, Flub E, Choy E, … and Jones GT. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis,2016;0:1-11.ta

11/07/2025

Chronic pain
Part 6: use and non-use of pain-related healthcare services
📍A recent qualitative paper by Mose et al. (2023) interviewed 20 people with chronic pain to explore how people with chronic pain explain their use and non-use of pain-related healthcare services. Four key drivers were identified:
HEALTHCARE SYSTEM FACILITATES CLINICAL PATHWAYS:
🗣️Patients with chronic pain move in system-defined sequences between specialties and sectors. Referrals are a common driver of pain-related healthcare.
APPRAISAL OF INITIATIVE INFLUENCE FUTURE USE:
🗣️Healthcare initiatives are evaluated by people with chronic pain and the outcome of this modifies their use of pain-related healthcare services. Previous experiences shape or create treatment prototypes that influence future pathways and use.
🗣️Patients with chronic want to be seen, heard and approached with interest by healthcare professionals.
🗣️Perceived improvement and alliance with healthcare professionals influence engagement and use.
AUTONOMY, BELIEFS & VALUES DETERMINE HEALTH BEHAVIOURS:
🗣️Healthcare use and clinical pathways are often determined and influenced by patient preferences, beliefs and values, and should endeavour to adapt to peoples’ needs.
🗣️Healthcare should be effective, efficient, manageable and feasible.
🗣️Peoples’ pain beliefs and quest for diagnostic certainty drive healthcare choices and behaviours! Pain and functional limitations necessitate a call for action.
RECOMMENDATIONS IMPACT HEALTH BEHAVIOURS:
🗣️Recommendations for others, relatives and healthcare professionals are powerful drivers for treatment pathways, including the use of alternative medicine and therapies.
🗣️Disease and treatment explanations are critically important to help shape patient understanding and expectations.
CONCLUSIONS:
⚠️The ways in which people with chronic pain engage with pain-related healthcare services is diverse, and a worthwhile consideration in order to understand their needs, preferences and expectations among other factors.
MW
Reference:
Mose S, Budtz CR, Smidt HR, Kent P, Smith A, Andersen JH, Christiansen DH. How do people with chronic pain explain their use, non-use, of pain-related healthcare services? A qualitative study of patient experiences. Disability and Rehabilitation,2023;45(25):4207-4217.

11/07/2025

Chronic pain
Part 5: perceived needs of people living with chronic pain
📍A recent scoping review by Gervais-Hupe et al. (2024) collated the data of 96 studies to explore the perceived needs of people with chronic pain from a physiotherapy point-of-view. Several major themes were identified across three levels: individual-, process- and organisational-levels.
DEFINITION:
🗣️”Perceived needs” relate to any demands, preferences or expectation from patients towards physiotherapy services, based on their experiences, beliefs and values. Patient collaboration and active involvement are important.
INDIVIDUAL LEVEL
🔆Interpersonal care: the inherent need to be understood, respected and validated, and to maintain an empathetic, trusting and supportive relationship with their physiotherapist.
🔆Individualised care: the need for individuals to have their beliefs, expectations and past experiences considered in the decision-making processes that can influence their overall management and subsequent experiences.

PROCESS LEVEL
🔆Coordination and continuity: the long-term planning of care with collaboration and transitions among health care providers and services.
🔆Professional care: all aspects of clinical care, including patient education, professional expertise and treatment guidelines.
ORGANISATIONAL LEVEL
🔆Data and information: the ways health information is shared to patients, encompassing elements related to the availability, security and transparency of patient data and performance indicators.
🔆Services and facilities: the structural aspects of healthcare facilities and staffing, including the physical environment, atmosphere and accessibility.
🔆Access: the geographic and timely access of services and the associated costs.
CONCLUSIONS:
⚠️“How can we help you?” – a common question from healthcare professionals and services designed to understand the perceived needs of health consumers, which should encompass the three levels of care including the individual-, process- and organisational levels.
MW
Reference:
Gervais-Hupe J, Filleul A, Perreault K, Gaboury I, Wideman TH, Charbonneau C, Loukili F, Beauvais R, Campeau MA, Jacob G, Lasnier N, Hudon A. “How can we help you?”: results of a scoping review on the perceived needs of people living with chronic pain regarding physiotherapy. BMC Health Services Research,2024;24:1401.

03/07/2025

Chronic pain
Part 4b: care experiences with pain and mental health conditions
📍A recent systematic review by Klem et al. (2025) collated the data of 22 studies with over 240 adolescent participants to systematically analyse their lived and care experiences with chronic pain alongside at least one mental health condition.
BACKGROUND:
🔎Chronic pain and mental health conditions are interconnected, significantly impacting young people’s lives, identities and socialisation, yet services for each are often inadequate and poorly integrated.
CARE EXPERIENCES (3 themes):
🔎Defined as experiences relating to seeking or receiving any aspect of health or social care. This also includes one’s expectations, values, preferences and priorities for their care.
🗣️Navigating healthcare systems: and accessing coordinated, integrated and age-relevant care represents a significant burden and can exacerbate pain and mental health. There appears to be a correlation between one’s level of support and their feelings of being empower as one transitions from adolescent to adult healthcare services.
🗣️Receiving appropriate care: diagnosis is one element that can result in a sense of relief, whilst also inducing stress, fear and worry. Barriers to healthcare access and affordability were commonly described. Age-appropriate education, digital resources and services that promote interpersonal engagement are all key preferences and priorities.
🗣️Point-of-care experiences & care preferences: Making sense of complex emotions and their interaction with pain was a key priority area, alongside the need for young people to feel comfortable, validated and understood by health professionals. Young people value strong therapeutic relationships and individualised care.
CONCLUSIONS:
⚠️The mechanisms and interplay of chronic pain and mental health require deeper exploration, including how young people may be better supported with personalised, holistic, developmentally and/or life-stage-appropriate integrated care.
MW
Reference:
Klem NR, Slater H, Rowbotham S, Chua J, Waller R, Stinson JN, Romero L, Lord SM, Troy B, Schutze R, Briggs AM. Lived and care experiences of young people with chronic musculoskeletal pain and mental health conditions: a systematic review with qualitative evidence synthesis. Pain,2025;166:732-754.

03/07/2025

Chronic pain
Part 4a: lived experiences with pain and mental health conditions
📍A recent systematic review by Klem et al. (2025) collated the data of 22 studies with over 240 adolescent participants to systematically analyse their lived and care experiences with chronic pain alongside at least one mental health condition.
BACKGROUND:
🔎Chronic pain and mental health conditions are interconnected, significantly impacting young people’s lives, identities and socialisation, yet services for each are often inadequate and poorly integrated.
LIVED EXPERIENCES (4 themes):
🔎Defined as the physical, psychological or social experiences.
🗣️2-way relationship between chronic pain and mental health: manifesting as a negative impact on an individual’s overall wellbeing. Ultimately, chronic pain can influence one’s emotions and cognitions, and conversely, emotions and cognitions can affect their pain experience.
🗣️Psychosocial implications of chronic pain: individuals often describe a directional relationship between their pain state and mental health , where experiences of one can exacerbate the other and vice versa. The complex relationship of each condition can influence a young person’s sense of identity and self, as well as their interpersonal relationships, and level of engagement in work, study and physical activity.
🗣️Uncertainty about future: negative expectations or concerns about one’s future often aligns with uncertainty and a degree of anguish. Worry and anxiety related to making the right treatment decisions was also described.
🗣️Coping with chronic pain and mental health conditions: a bidirectional relationship was described between how one’s ability to cope can affect their emotions and cognitions, and vice versa. Efforts in coping takes an emotional tole on young people.
CONCLUSIONS:
⚠️The mechanisms and interplay of chronic pain and mental health require deeper exploration, including how young people may be better supported with personalised, holistic, developmentally and/or life-stage-appropriate integrated care.
MW
Reference:
Klem NR, Slater H, Rowbotham S, Chua J, Waller R, Stinson JN, Romero L, Lord SM, Troy B, Schutze R, Briggs AM. Lived and care experiences of young people with chronic musculoskeletal pain and mental health conditions: a systematic review with qualitative evidence synthesis. Pain,2025;166:732-754.

02/07/2025

Chronic pain
Part 3: lived experiences
📍A recent systematic review by van Rysewyk et al. (2023) collated the data of 20 qualitative studies to synthesize the themes that underpin the lived experiences of people with chronic pain. Eight themes emerged:
🗣️“My pain gives rise to negative emotions”: living with pain negatively affects mental health and the deterioration of mental well-being secondary to living with pain.
🗣️“Changes to my life and to myself”: living with pain changes the everyday activities and roles that can be performed and has a profound impact on expectations of the future, which together form a threat to one’s perceived self and identity.
🗣️“Adapting to my new normal”: living with pain requires adaptation and a degree of acceptance. Age and gender roles and responsibilities may undergo changes.
🗣️“Effects of my pain management strategies”: strategies to limit pain, such as avoidance of activities and self-medication can have negative consequences on mental and social well-being, including isolation, depression or alienation from others. Conversely, strategies that improve mental and social well-being are favourable.
🗣️“Hiding and showing my pain”: living with pain can involve secrecy, shame and hiding because individuals believe revealing pain can lead to negative responses and judgement from others.
🗣️“Medically explaining my pain”: a search for a diagnosis is associated with personal credibility, validation and reassurance. Questioning the legitimacy of one’s pain is extremely unhelpful.
🗣️“Relationships to those around me”: living with pain impacts social, professional and familial relationships. Individuals tend to have difficulty communicating effectively about their pain.
🗣️“Working while in pain”: working with pain will often require additional support and/or modifications at work, however conveying this is challenging and often underpinned by fear.
CONCLUSIONS:
⚠️This large paper outlines some important and generalisable themes that underpin the lived experiences of individuals living with chronic pain.
MW
Reference:
Van Rysewyk S, Blomkvist R, Chuter A, Crighton R, Hudson F, Roomes D, Smith BH, Toye F. Understanding the lived experience of chronic pain: a systematic review and synthesis of qualitative evidence syntheses. British Journal of Pain,2023;17(6):592-605.

02/07/2025

Chronic pain
Part 2: perceived barriers to effective pain management
📍A recent qualitative paper by Hadi et al. (2017) conducted a secondary analysis of semi-structured interviews with 19 participants with chronic pain to explore the perceived barriers to effective pain management.
THEMES:
HEALTHCARE PROFESSIONAL:
🗣️Lack of interest and empathy: Practitioners must understand the impact chronic pain has on an individual's daily life, approaching each case with empathy and without judgment.
🗣️Lack of specialised knowledge: individuals want a selection of multidimensional treatment options that are individually-tailored and patient-centred.
🗣️Lack of interprofessional communication: a common barrier that tended to lead to inconsistencies in management, unnecessary referrals and a clash of opinions.
HEALTH SYSTEMS:
🗣️Long waiting times: delayed care contributes to patient frustration, dissatisfaction and poorer perceived outcomes.
🗣️Short consultation times: Individuals want their story to be heard so they can be understood holistically and have their unique needs recognized and met.
🗣️Lack of an integrated multidisciplinary approach: individuals want to be managed collaboratively as whole persons, rather than viewed through a unidimensional, pathology-focused lens.
CONCLUSIONS:
⚠️The main perceived barriers faced by individuals with chronic pain when accessing healthcare were largely related to both individual healthcare professionals and the broader healthcare system. These barriers should be acknowledged and become the focus of a targeted approach to improve healthcare delivery and health outcomes in the context of chronic pain.
MW
Reference:
Hadi MA, Alldred DP, Briggs M, Marczewski K, Closs SJ. ‘Treated as a number, not treated as a person’: a qualitative exploration of the perceived barriers to effective pain management of patients with chronic pain. BMJ Open,2017;7:e016454

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