Beneficial Effects of Improvement in Depression, Pain Catastrophizing, and Anxiety on Pain Outcomes: A 12-Month Longitudinal Analysis


Depression, pain catastrophizing, and anxiety commonly co-occur with chronic pain. However, the degree to which improvement in these psychological comorbidities predicts subsequent pain outcomes and, in particular, the relative effects of these 3 psychological factors with respect to one another is only partially known. Longitudinal analysis of 250 primary care patients with chronic musculoskeletal pain enrolled in the Stepped Care to Optimize Pain care Effectiveness (SCOPE) trial was examined, using data gathered at baseline, 3 and 12 months. Mixed effects model repeated measures (MMRM) analyses were used to determine if changes in depression, pain catastrophizing, and anxiety predicted a subsequent reduction in pain intensity/interference and pain-related disability. Defining a clinically significant change as twice the standard error of measurement (SEM) for each predictor, a 2-SEM improvement in depression, pain catastrophizing, and anxiety resulted in, respectively, an effect size decrease in pain intensity/interference of 0.45, 0.33, and 0.12; a 14%, 12%, and 6% reduction in the number of pain-specific disability days; and a 43%, 30%, and 28% decreased likelihood of high disability (defined as ≥ 10 pain-specific disability days in the past 4 weeks).

In summary, improvements in 3 common psychological comorbidities predict better pain outcomes.


Product Innovation Funding via Design Council Spark

Screen Shot 2015-11-26 at 7.27.00 AM

The UK Arthritis Foundation and Design Council has added a product innovation fund to help fund inventors for products that improve quality of life and independence for arthritis sufferers. Design Council Spark is looking for products which can be sold to companies or individuals.

Applicants must be UK residents and plan on developing their product in the UK. Forty products will be selected to go on for further evaluation during a two day workshop. From that point on eight to twelve products will be selected as Spark Finalists. Finalists will receive a twenty week product support programme, access to prototyping materials and facilities, advice on investing and £15,000 to spend on development.

Up to top four products will be selected for the Spark Awards and will receive £150,000 from the Spark  research fund or £50,000 from Arthritis Research UK.

Read More Here

BACPAR Become Professional Partner


We are delighted to welcome British Association of Chartered Physiotherapists in Amputee Rehabilitation (BACPAR) to the team.

During the recent amputee rehabilitation course that we ran in Physiopedia we gathered over 500 amazing case studies from our participants.  This diverse set of case studies demonstrated current physiotherapy practice for individuals with amputation from all over the world, it seemed a crime not to share them.  We are very excited that BACPAR has agreed to sponsor the creation of a special section in Physiopedia where we will publish the very best of these case studies.

In addition to this, BAPCAR will become involved in the ongoing review of amputee related information in Physiopedia and also the open online course on amputee rehabilitation which will run again in the future.

BACPAR is a Professional Network of the Chartered Society of Physiotherapy(CSP). It was founded in 1993 to provide a nationwide network for physiotherapists involved in the specialist field of amputee and prosthetic rehabilitation. The organisation supports the promotion of evidence base practice and research, is committed to education, and provides a network for the dissemination of best practice in pursuit of excellence and equity, whilst maintaining cost effectiveness.

Thank you members of BACPAR!

Find out more about BACPAR

Looking For The Core Part 1 – What is Core Stability?


Back to the future: Part 1

Head of Education and Elite Sport Movement Consultant, Lincoln Blandford offers a refreshed view from his 2013 publication ‘Injury Prevention and Movement Control

Back in 2013 I was asked to write a book chapter on the much discussed and equally maligned topic – core stability (CST). The chapter finally concludes with the message that there is a need to move on, both in terms concept and terminology. Two years on, I revisit themes from that chapter in a two part blog, presenting a more contemporary perspective on this controversial subject. Ultimately, now, juts as then, the story comes back to the need to assess and retrain movement, employing a multi-joint, multi intensity tool such as ‘The Performance Matrix’ in order to benefit any one individual’s ‘Movement Health’, over their movement lifespan.

I realise now, the chapter’s title, ‘looking for the core, finding movement control’ summarises my own journey as a movement focussed trainer, operating within a performance outcome field and surrounded by conflicting information. This journey/investigation has taken the best part of 15 years and involved many false turns and periods of plateau. Back in 2013, the Movement Health concept (McNeill & Blandford, 2015) was in its early infancy; possessing choice in the achievement of movement outcomes opened new perspectives on the value of movement. Without the CST story that preceded it, this vista may never had appeared. Therefore, the concept should be thanked, as it has taken the importance of movement to a better place, but CST comes with baggage.

Yesterday’s pizza?

Core stability, as a concept, is about twenty years old. In the aim to reinforce this point and illustrate the need to consign it to history I once described CST as ‘yesterday’s pizza’, to Mark Comerford. Mark replied, ‘yes, but everybody knows what it tastes like.’ Mark’s right. Everyone has an opinion, an experience, and exercise when it comes to what started out as a therapeutic application of some research findings performed in the mid-90s. Core stability remains divisive; everybody has heard of it, but opinions can still differ on what it is and if it is worth pursuing, practically or even in a blog.

On the plus side, the original research that spawned the CST ‘revolution’ successfully established links between movement, pain & altered recruitment strategies; for bringing this knowledge to the literature, it should be acknowledged. Yet, the wild-fire success of CST was also somewhat of a curse as it became the answer to all movement questions, no matter in which movement related discipline professionals operated.

Core stability – what’s your style?

From the late 90s onwards CST gained world-wide recognition, adopted on a global scale, with huge variance & incongruence in its application. The original research was adapted to suit the training bias of the specific movement disciplines own cultural take on ‘effective’ training. Strength and performance focussed individuals developed core strength training to match force development focussed profiles. Rehab professionals oversaw the evolution of ‘motor control’, a low intensity version of core stability. Both camps, the high and the low intensity brigade, could mutually discredit their conceptual adversary as neither could achieve goals of the other.

A concept of two halves

So, who was right? Well, everyone, half of the time. Each approach (strength or motor control) could influence specific physiology of the body. Low intensity work could help address low intensity issues. High intensity work helped address high intensity problems. But if the low approach was used with the high problem a fix would not be found; and vice versa. Therefore, it was easy for some authors to say CST didn’t work; half the time, they were right.

‘Brooks (2012) strongly questions the validity of the whole CST approach, stating ‘athletes are probably wasting their valuable training time including core training in their routines’. Although less damning the Reed paper (2012) suggests core training is effective; though only for some. ‘

Function stranger than fiction?

Such literature led to a backlash; CST was more than just old hat, it was portrayed as a time waster. Fitness media and blogs began to replace CST with the term ‘functional training; an equally controversial topic. The strength and conditioning community started to discuss ‘neuromuscular training’; again, a term as non-specific as motor control or functional. Whilst replacing the term CST was necessary, many of the applications/research findings related to pain, movement & recruitment were also disregarded; tarred with the CST brush, useful applications to influence movement quality were considered redundant. The new fashions of functional and neuromuscular training demanded whole body integrated movement, performed at fatiguing intensity. The age of Cross Fit was here. Training approaches not fitting the mould were out; not trending. High intensity held the upper hand.


  • Allison, G. T., Godfrey, P., & Robinson, G. (1996). EMG signal amplitude assessment during abdominal bracing and hollowing. Electromyogr. Kinesio. 8:51-57.
  • Briggs, A. M., Greig, A. M., Wark, J. D., Fazzalari, N. L., Bennell, K. L. (2004). A review of anatomical and mechanical factors affecting vertebral body integrity. Int J Med Sci; 1(3):170-180.
  • Brooks, C. M. (2012). On rethinking core stability exercise programs. Australasian Musculoskeletal Medicine, June: 9-14.
  • Caraffa, A., G., Cerulli, M., Projetti, G., Aisa, & Rizzu, A. (1996). Prevention of anterior cruciate ligament injuries in soccer: A prospective controlled study of proprioceptive training. Knee Surg. Sports Traumatol. Arthrosc. 4:19–21.
  • Comerford, M. J. (2013). Personal communication.
  • Comerford, M. J. & Mottram, S. L. (2012). Kinetic Control: The Management of Uncontrolled Movement. Churchill Livingstone. Elsevier. Australia.
  • Drysdale, C. L., Earl, J. E., & Hertel, J. (2004). Surface Electromyographic Activity of the Abdominal Muscles During Pelvic-Tilt and Abdominal-Hollowing Exercises. Journal of Athletic Training. ;39:32–36.
  • Faries, M. D., & Greenwood, M. (2007). Core Training: stabilizing the confusion. Strength and Conditioning Journal, 29, 10-25.
  • Fitzgerald, G. K., Ake, M. J., & Snyder-Mackler, L. (2000). The efficacy of perturbation training in nonoperative anterior cruciate ligament rehabilitation programs for physically active individuals. Phys. Ther. 80:128– 140.
  • Griffın, L. Y., Albohm, M. J., Arendt, E. A., et al. (2006). Understanding and preventing noncontact anterior cruciate ligament injuries: a review of the Hunt Valley II meeting, January 2005. Am J Sports Med;34(9):1512–1532.
  • Hodges, P. W., & Moseley, G. L. (2003). Pain and motor control of the lumbopelvic region: effect and possible mechanismsJournal of Electromyography and Kinesiology 13, 361–370.
  • Hodges, P. W., & Richardson, C. A. (1996). Inefficient muscular stabilisation of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine;21:2640-2650.
  • Kavic, N., Grknier, S., & Mcgill, S. M. (2004a). Determining the stabilizing role of individual torso muscles during rehabilitation exercises. Spine. 29:1254- 1265.
  • Kibler, W. B., Press, J., & Sciascia, A (2006). The Role of Core Stability in Athletic Function Sports Med; 36 (3): 189-198.
  • Lederman, E. (2010). The myth of core stability. Journal of Bodywork & Movement Therapies. 14, 84-98.
  • McGill, S. M. (2001). Low back stability: From formal description to issues for performance and rehabilitation. Exercise Sport Science Review, 29, 26–31.
  • McGill, S. M., Grenier, S., Kavcic, N., & Cholewicki, J. (2003). Coordination of muscle activity to assure stability of the lumbar spine. J. Electromyogr.Kinesiol. 13:353–359.
  • Myer, G. D., Ford, K. R. & Hewett. T. E. (2004). Methodological approaches and rationale for training to prevent anterior cruciate ligament injuries in female athletes. Scand. J. Med. Sci. Sports 14:275–285.
  • Panjabi, M. M. (1992). The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement, Journal of Spinal Disorders 5 (4), 383–389.
  • Paterno, M. V., Myer, G. D., Ford, K. R., & Hewett. T. E. (2004). Neuromuscular training improves single-limb stability in young female athletes. J.Orthop. Sports Phys. Ther. 34:305–316.
  • Reed, C. A., Ford, K. R., Myer, G. D., & Hewett, T. E. (2012). The effects of isolated and integrated ‘core stability’ training on athletic performance measures: a systematic review. Sports Med. 1;42:697-706.
  • Reeves, N. P., & Cholewicki, J. (2003). Modeling the human lumbar spine for assessing spinal loads, stability, and risk of injury. Crit Rev Biomed Eng;31:73–139.
  • Reeves, N. P., Narendrac, K. S., & Cholewickia, J. (2007). Spine stability: the six blind men and the elephant. Clin Biomech (Bristol, Avon); 22: 266–274.
  • Roussel, N. A., Nijs, J., Mottram, S., van Moorsel, A., Truijen, S., & Stassijns, G. (2008). Altered lumbopelvic movement control but not generalised joint hypermobility is associated with increased injury in dancers. A prospective study. Manual Therapy (on line).
  • Sahrmann, S. (2002). Diagnosis and Treatment of Movement Impairment Syndromes. Mosby.
  • Saner, J., Kool, J., de Bie, R. A., Sieben, J. M., & Luomajoki, H. (2011). Movement control exercise versus general exercise to reduce disability in patients with low back pain and movement control impairment. A randomised controlled trial. BMC Musculoskelet Disord; 12: 207.
  • STOTT Pilates (2012).
  • Thacker, S. B., Gilchrist, J., Stroup, D. F., Kimsey, C. D. (2002). The prevention of shin splints in sports: a systematic review of literature. Med Sci Sports Exerc;34(1):32– 40.
  • Thacker, S. B., Stroup, D. F., Branche, C. M., Gilchrist, J., Goodman, R. A., Weitman, E. A. (1999). The prevention of ankle sprains in sports. A systematic review of the literature. Am J Sports Med;27(6):753– 760.
  • Thacker, S. B, Stroup, D. F., Branche, C. M., Gilchrist, J., Goodman, R. A., Porter Kelling, E. (2003). Prevention of knee injuries in sports. A systematic review of the literature. J Sports Med Phys Fitness; 43:165–79.
  • Tsao, H., Galea, M. P., & Hodges, P. W. (2008). Reorganization of the motor cortex is associated with postural control deficits in recurrent low back pain. Oxford Journals Medicine Brain; 131, 2161-2171.
  • Verhagen, E. A., van Mechelen, W., de Vente, W. (2000). The effect of preventive measures on the incidence of ankle sprains. Clin J Sport Med;10(4):291– 296.
  • Wand, B. M., Parkitny, L., O’Connell, N. E., Luomajoki, H., McAuley, J. H., Thacker, M., Moseley, G. L. (2011). Cortical changes in chronic low back pain: Current state of the art and implications for clinical practice. Manual Therapy; 16, 15-20.
  • White, A. A., Panjabi, M. (1978). Clinical biomechanics of the spine. Philadelphia Toronto: J.B.Lippincott Company.
  • Willardson, J. M. (2007). Core stability training: applications to sports conditioning programs. J Strength Cond Res. 21:979-985.
  • Yeung, E. W., Yeung, S. S. (2001). Asystematic review of interventions to prevent lower limb soft tissue running injuries. Br J Sports Med 2001;35(6):383–389.
  • Zazulak, B. T., Hewett, T. E., Reeves, N. P., Goldberg, B., & Cholewicki, J. (2007). Deficits in neuromuscular control of the trunk predict knee injury risk: a prospective biomechanical-epidemiologic study. Am J Sports Med; 35, 1123-1130.

Part 2 of this post to follow next week

One Million Visits – Thank You!

from on to one million

We did it!  In October this year Physiopedia had over 1 million page views!!

Everyone here in the office has been waiting for this day for some time now.  Earlier this year when I gave a keynote presentation at the Canadian Physiotherapy Conference my story was based on the rise of Physiopedia from it’s birth to over one million visits in one month.  We didn’t quite manage it in time for my presentation but now we have.  How amazing is that!!

One million page views for Physiopedia

The popularity of Physiopedia really highlights the thirst for physiotherapy related information. Physiopedia is just one of many places that we can provide that information.  What is great about Physiopedia though is that it is a community built resource, any physiotherapist or physical therapist around the world can make edits at anytime.  The more we, you, contribute the better the resource gets.  So join us, if you have expertise in a particular topic or if you simply see something that needs updating or correcting, login and make your contribution.

Today in the United States is Thanksgiving so we’d like to take this opportunity to say a huge thank you to each and every one of you that has contributed to the rise of Physiopedia.  You are all awesome!

michael jordan making it happen

Effectiveness of workplace interventions in the prevention of upper extremity musculoskeletal disorders and symptoms: an update of the evidence.


The burden of disabling musculoskeletal pain and injuries (musculoskeletal disorders, MSDs) arising from work-related causes in many workplaces remains substantial. There is little consensus on the most appropriate interventions for MSDs. Our objective was to update a systematic review of workplace-based interventions for preventing and managing upper extremity MSD (UEMSD). We followed a systematic review process developed by the Institute for Work & Health and an adapted best evidence synthesis. 6 electronic databases were searched (January 2008 until April 2013 inclusive) yielding 9909 non-duplicate references. 26 high-quality and medium-quality studies relevant to our research question were combined with 35 from the original review to synthesise the evidence on 30 different intervention categories.

There was strong evidence for one intervention category, resistance training, leading to the recommendation: Implementing a workplace-based resistance training exercise programme can help prevent and manage UEMSD and symptoms. The synthesis also revealed moderate evidence for stretching programmes, mouse use feedback and forearm supports in preventing UEMSD or symptoms. There was also moderate evidence for no benefit for EMG biofeedback, job stress management training, and office workstation adjustment for UEMSD and symptoms. Messages are proposed for both these and other intervention categories.

The influence of chronic pain on post-operative pain and function after hip surgery: a prospective observational cohort study

Neuropathic Pain

Pre-existing or chronic pain is an established risk factor for severe post-operative pain. In this prospective observational cohort-study, we investigate whether a history of chronic pain, beyond the presence of hip-related pain, affects other post-operative factors including early mobilization, function, and psychological distress following hip surgery.

Patients undergoing total hip replacement surgery were observed from the pre-operative day until the seventh post-operative day. Prior to surgery, they were characterized by their pain history, pain intensity, function and psychological characteristics. Post-operatively, pain intensity was evaluated on day 1, 3, 5 and 7 and the analgesic consumption was recorded for each of these days. Measures of function (functional questionnaire, ability to mobilize and to climb stairs and range of hip motion) and psychological distress were re-evaluated on day 7. A history of chronic pain was associated with slower postoperative mobilization, poorer physical function and higher psychological distress in addition to increased post-operative pain intensity. The co-morbidity of a chronic pain disorder results in higher pain intensity post-surgery, and also impedes postoperative rehabilitation. Identifying patients with a chronic pain disorder is necessary pre-operatively so that appropriate pain management and rehabilitation can be planned to facilitate recovery.

Chronic pain, beyond the presence of hip-related pain, is associated with slower postoperative mobilization, poorer physical function and higher psychological distress following total hip replacement surgery. Identifying patients with chronic pain and establishing multiprofessional perioperative management might improve postoperative rehabilitation of patients with chronic pain.