Papers by RAMAKRISHNAN MANI
Neuromodulation, Jun 1, 2023
The Lancet Rheumatology, Aug 1, 2021
Physical Therapy Reviews, Dec 23, 2019
Background: The chronic musculoskeletal pain (CMP) epidemic occurs concurrently during historical... more Background: The chronic musculoskeletal pain (CMP) epidemic occurs concurrently during historical mass population movements and significant income inequities. Epidemiological studies indicate CMP may occur disproportionately in marginalized populations. Nationalistic rhetoric has arisen, in part, due to perceived concerns over access to healthcare. Political policies directly and indirectly impact healthcare. Objectives: To explore 1) how potential historical, societal, and political factors may contribute to the clinical conversation of pain; 2) the impact ineffective clinical conversations may have on the CMP experience. Methods: Literature Review. Major Findings: CMP is an invisible disease decoupled from normal tissue healing. The clinical conversation is increasingly recognized to impact treatment outcomes. The clinician and the patient bring differing histories, values, and interpretations to clinic visits. Systemic healthcare racism, implicit biases, incongruent provider/patient assessment of pain, and provider stigmatization contribute to olgioanalgesia. As healthcare professional groups become more politically active, providers bring that political experience into the clinic. Marginalized populations, at risk for greater stress, discrimination, and fear bring their own intensified political perceptions into the clinic. We suggest that poor management and discordant clinical conversation may be adversely influenced by the current political climate. Conclusion: Identifying contributing factors to ineffective clinical conversations is important to improve CMP outcomes and to minimize inequities in CMP management. We hope to identify populations that may be more vulnerable to political biases, understand factors in the clinical conversation that are important to patients, and to build opportunities to educate providers and patients on these forces impacting the clinical conversation.
Medical Hypotheses, Aug 1, 2019
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service... more This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Central hypersensitivity-a model for persistent musculoskeletal pain in inflammatory bowel diseases.
The Lancet Rheumatology, May 1, 2021
Summary Chronic pain is a leading cause of disability globally and associated with enormous healt... more Summary Chronic pain is a leading cause of disability globally and associated with enormous health-care costs. The discrepancy between the extent of tissue damage and the magnitude of pain, disability, and associated symptoms represents a diagnostic challenge for rheumatology specialists. Central sensitisation, defined as an amplification of neural signalling within the CNS that elicits pain hypersensitivity, has been investigated as a reason for this discrepancy. Features of central sensitisation have been documented in various pain conditions common in rheumatology practice, including fibromyalgia, osteoarthritis, rheumatoid arthritis, Ehlers-Danlos syndrome, upper extremity tendinopathies, headache, and spinal pain. Within individual pain conditions, there is substantial variation among patients in terms of presence and magnitude of central sensitisation, stressing the importance of individual assessment. Central sensitisation predicts poor treatment outcomes in multiple patient populations. The available evidence supports various pharmacological and non-pharmacological strategies to reduce central sensitisation and to improve patient outcomes in several conditions commonly seen in rheumatology practice. These data open up new treatment perspectives, with the possibility for precision pain medicine treatment according to pain phenotyping as a logical next step. With this view, studies suggest the possibility of matching non-pharmacological approaches, or medications, or both to the central sensitisation pain phenotypes.
Psychological Medicine, May 10, 2023
Tracing the origins of midlife despair: association of psychopathology during adolescence with a ... more Tracing the origins of midlife despair: association of psychopathology during adolescence with a syndrome of despair-related maladies at midlife.
The New Zealand journal of physiotherapy, May 10, 2023
STarT Back is a stratified care approach to identify and manage psycho-social factors for persist... more STarT Back is a stratified care approach to identify and manage psycho-social factors for persisting low back pain and associated disability. A STarT Back course was held at the School of Physiotherapy, University of Otago, in June 2019, introducing a small cohort of physiotherapists (n = 20) to the approach, including psychologically informed interventions. The study aim was to gain insight into these physiotherapists’ perceptions of the feasibility of implementing STarT Back in their own practice and more widely in New Zealand. Semi-structured focus group interviews were conducted with 14 physiotherapists who attended the training course and had subsequently used STarT Back to different extents in their own practice. Data were analysed using reflexive thematic analysis. Six themes were identified: confidence in current practice; STarT Back as a useful framework; concerns over the low-risk group; difficulties in translation; education is essential; and behaviour change. The need for behaviour change was a unifying theme with interpretation aided by the Capability, Opportunity, and Motivation Behaviour (COM-B) model. Practical suggestions to enhance implementation were made, with participants identifying strategies that promoted use of STarT Back in their practice. Issues identified included concerns about care for low-risk patients, health system structure and funding, and resistance to changing usual practice. Participants were cautious about the feasibility of wider implementation of STarT Back in New Zealand.
The New Zealand journal of physiotherapy, Mar 1, 2020
Physiotherapists in Aotearoa New Zealand use various models and tools for assessing pain, many of... more Physiotherapists in Aotearoa New Zealand use various models and tools for assessing pain, many of which have been developed and validated in other ethnic populations outside Aotearoa New Zealand. In particular, assessing pain within the Mäori population should be culturally appropriate and capture Mäori realities associated with pain experience. The purpose of this systematic review was threefold: to explore evidence of pain experiences among Mäori, to identify any pain assessment questionnaires that capture Mäori experiences of pain, and to propose a framework to evaluate the adherence to kaupapa Mäori research guidelines. Due to the gap in the literature, only two studies were eligible. Based on these two studies, whänau, Mäori holistic views of health, whakapapa, and spirituality were identified as key themes associated with Mäori pain experiences. The quality of included studies was "medium-high" and "high". The overall evaluation based on the Confidence in the Evidence from Reviews of Qualitative research demonstrated "high-moderate" confidence in the findings. Evaluation of adherence to a kaupapa Mäori theory framework of the included studies found these to be limited. This review could not identify culturally valid tools to capture Mäori experiences of pain, and established the need to develop tools encompassing themes associated with Mäori experiences of pain.
Physical Therapy Reviews, Feb 1, 2017
Background: Physiotherapy plays an important role in management of acute nonspecific low back pai... more Background: Physiotherapy plays an important role in management of acute nonspecific low back pain (NSLBP). However, there is a relative dearth of information about the current clinical practice for management of NSLBP and its relationships with clinical outcomes of pain and function. Objective: To investigate the current physiotherapy practice patterns in management of acute NSLBP in New Zealand (NZ), and determine its relationships with clinical outcomes of pain and function. Methods: A prospective observational cohort study, using data from private physiotherapy clinics, was conducted. Physiotherapists at each clinic completed a treatment summary form at time of discharge. Treatment techniques used and clinical outcome of pain [numeric pain rating scale (NPRS)] and function [Patient-specific Function scale (PSFS)] were extracted from recorded notes. Raw values of NPRS and PSFS were converted to percentage of available change scores and used for further analysis. Results and Conclusions: A total of 199 data-sets of acute NSLBP patients were included in the analysis. A wide variety of treatment techniques were used by NZ physiotherapists, with joint mobilization being the most popular form of treatment choice (88%), often combined with specific exercises and massage (21%). Linear regression analysis demonstrated a significant positive association between joint mobilization and massage and patient's function, and pain and function, respectively; whereas, a significant negative association between specific exercises and patient's function. The most popular form of treatments used by NZ physiotherapists' lacks support from evidence-based clinical guidelines, but still seems to be effective in reducing pain and improving function.
Scandinavian Journal of Pain, May 21, 2021
Objectives: Increased symptoms related to central sensitization have previously been reported in ... more Objectives: Increased symptoms related to central sensitization have previously been reported in inflammatory bowel disease (IBD) patients, identified by the original central sensitization inventory (CSI-25). However, the recently developed CSI short form (CSI-9) may be more clinically useful. The aim of the present study was to evaluate the performance of CSI-9 compared to the original CSI-25 in individuals with IBD. Study objectives were to investigate the criterion validity of the CSI-9 to the CSI-25, assess individual association of the CSI measures with clinical features of IBD and pain presentations, and to establish diseasespecific CSI-9 and CSI-25 cutoff scores for discriminating the presence of self-reported pain in individuals with IBD. Methods: Cross-sectional online survey was performed on adults with IBD exploring self-reported demographics, comorbidity, and clinical IBD and pain features. Criterion validity of the CSI-9 was investigated using intraclass correlation coefficient (ICC) 3,1. Area under the receiver operating characteristic curve (AUC-ROC) analysis was conducted to investigate the discriminative ability of both versions of CSI. Results: Of the 320 participants, 260 reported the presence of abdominal and/or musculoskeletal pain. CSI-9 and CSI-25 demonstrated substantial agreement (ICC 3,1 =0.64, 95% CI [0.58, 0.69]). AUC (95% CI) indicated that CSI-9 (0.788 (0.725, 0.851), p<0.001) and CSI-25 (0.808 (0.750, 0.867), p<0.001) were able to adequately discriminate the presence of pain using cutoffs scores of ≥17 (CSI-9) and ≥40 (CSI-25). Abdominal pain severity was the only feature to differ in significant association to CSI-25 (p=0.002) compared to CSI-9 (p=0.236). All other features demonstrated significant associations to both CSI versions, except age (p=0.291 and 0.643) and IBD subtype (p=0.115 and 0.675). Conclusions: This is the first study to explore and validate the use of CSI-9 in IBD patients. Results demonstrated concurrent validity of the CSI-9 to CSI-25, with similar significant association to multiple patient features, and a suggested cutoff value of 17 on CSI-9 to screen for individuals with pain experiences. Study findings suggest that CSI-9 is suitable to use as a brief tool in IBD patients.
Scandinavian Journal of Pain, Oct 28, 2020
Objectives: Musculoskeletal (MSK) pain is a common complaint in patients with inflammatory bowel ... more Objectives: Musculoskeletal (MSK) pain is a common complaint in patients with inflammatory bowel diseases (IBD). MSK pain in IBD has previously demonstrated association with symptoms of central sensitization; however it is uncertain whether these symptoms are influenced simply by the presence of MSK pain and/or IBD. Primary aim of this study was to investigate whether symptoms of central sensitization differed across three groups: IBD patients with and without MSK pain and healthy controls. Secondary aim was to investigate between-group differences for measures of somatosensory functioning. Methods: Cross-sectional study was performed on adults with IBD. Assessments included: central sensitization inventory (CSI), pressure pain threshold, temporal summation, conditioned pain modulation, perceived stress, affect style, anxiety, depression, and pain catastrophizing. One-way analyses of variance and covariance were used to investigate between-group differences for measures of central sensitization and potential confounding by psychological factors. Results: Study participants (n=66) were age/gender matched across three study groups. Between-group differences were solely demonstrated for CSI scores [F(2,63)=19.835, p<0.001, r=0.62], with IBD patients with MSK pain demonstrating the highest CSI scores and healthy controls the lowest. After controlling for individual psychological features, post hoc comparisons indicated that CSI scores were significantly different between-groups (p≤0.025) after controlling for most psychological variables, with the exception of perceived stress (p=0.063) and pain catastrophizing (p=0.593). Conclusions: IBD patients as a whole demonstrated significantly greater symptoms of central sensitization compared to healthy controls. However, IBD patients with persistent MSK pain demonstrated the greatest symptoms of central sensitization compared to patients without MSK pain and healthy controls. Between-group differences for CSI in IBD patients with MSK were not confounded by psychological features. Implications: Study results indicate that persistent MSK pain in IBD represents patients with greater central sensitization symptomology. This increased symptomology is suggestive of underlying mechanisms related to central sensitization, highlighting patient potentially at risk for worse pain experiences.
The Clinical Journal of Pain, Nov 18, 2019
Objective: Somatosensory abnormalities are linked to clinical pain outcomes in individuals with s... more Objective: Somatosensory abnormalities are linked to clinical pain outcomes in individuals with spinal pain. However, a range of factors might confound the relationship between altered somatosensory function and clinical pain outcomes. This systematic review aimed to evaluate the literature to assess the level of evidence of associations between psychological, social, physical activity, and sleep measures and somatosensory function (assessed via sensory psychophysical testing) among individuals with spinal pain. Methods: A comprehensive literature search was performed in 6 electronic databases from their inception to June 2018. Two reviewers independently assessed the methodological quality using a modified Quality in Prognostic Studies (QUIPS) tool and supplemented with recommendations from the Critical Appraisal and Data Extraction for the Systematic Review of Prediction Modelling Studies (CHARMS) checklist and the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. The level of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system. Data were pooled to evaluate the strength of the relationships of interest. Results: Among the 17 factors identified in the included studies, pain catastrophizing, depression, and pain-related fear have significant negative (small to fair) associations with pain thresholds. A “very low” to “moderate” quality of evidence was found for all the investigated factors. Subgroup analysis showed a smaller effect size for pain catastrophizing/fear of movement and pain thresholds in individuals with low back pain. Conclusions: Psychological factors are associated negatively with pain thresholds and they need to be adjusted when establishing predictive relationships between somatosensory function and pain outcomes in individuals with spinal pain.
Pain reports, Sep 1, 2019
Introduction: Higher physical activity (PA) and lower sedentary behaviour (SB) levels have demons... more Introduction: Higher physical activity (PA) and lower sedentary behaviour (SB) levels have demonstrated beneficial effects on temporal summation (TS) and conditioned pain modulation (CPM) in healthy adults. This cross-sectional study investigated the relationships between PA and SB and TS/CPM responses in individuals with chronic musculoskeletal pain. Methods: Sixty-seven middle-aged and older adults with chronic musculoskeletal pain were recruited from the community. Questionnaires measuring demographics, pain, and psychological measures were completed. Physical activity/SB levels were measured using the International Physical Activity Questionnaire-short form and Sedentary Behaviour Questionnaire, respectively. Semmes monofilament was used to assess mechanical TS (MTS) at the most symptomatic (MTS-S) and a reference region (MTS-R); change in the pain scores (baseline-10th application) was used for analysis. Conditioned pain modulation procedure involved suprathreshold pressure pain threshold (PPT-pain4) administered before and after (CPM30sec, CPM60sec, and CPM90sec) conditioning stimulus (2 minutes; ;12˚C cold bath immersion). For analysis, PPT-pain4 (%) change scores were used. Results: PPT-pain4 (%) change scores at CPM30sec and CPM60sec demonstrated significant weak positive correlations with SB levels and weak negative correlations with PA measures. After adjusting for confounding variables, a significant positive association was found between SB (h/d) and PPT-pain4 (%) change scores at CPM30sec and CPM60sec. No significant associations between MTS and PA/SB measures. Conclusion: Sedentariness is associated with higher pain inhibitory capacity in people with chronic musculoskeletal pain. The observed relationship may be characteristic of a protective (sedentary) behaviour to enhance pain modulatory mechanism. Prospective longitudinal studies using objective PA/SB measures are required to validate the observed relationship in a larger sample size.
BMJ Open, Aug 1, 2023
Chapple CM, et al. Initial effect of high-volume mobilisation with movement on shoulder range of ... more Chapple CM, et al. Initial effect of high-volume mobilisation with movement on shoulder range of motion and pain in patients with rotator cuff-related shoulder pain: protocol for a randomised controlled trial (Evolution Trial). BMJ Open 2023;13:e069919.
Journal of society of Indian physiotherapists, 2023
The Clinical Journal of Pain, Jun 19, 2023
Background: Knee osteoarthritis (OA) is a prevalent, painful, and disabling musculoskeletal condi... more Background: Knee osteoarthritis (OA) is a prevalent, painful, and disabling musculoskeletal condition. One method that could more accurately monitor the pain associated with knee OA is ecological momentary assessment (EMA) using a smartphone. Objectives: The aim of this study was to explore participant experiences and perceptions of using smartphone EMA as a way of communicating knee OA pain and symptoms following participating in a 2-week smartphone EMA study. Materials and Methods: Using a maximum variation sampling method, participants were invited to share their thoughts and opinions in semistructured focus group interviews. Interviews were recorded and transcribed verbatim before thematic analysis using the general inductive approach. Results: A total of 20 participants participated in 6 focus groups. Three themes and 7 subthemes were identified from the data. Identified themes included: user experience of smartphone EMA, data quality of smartphone EMA, and practical aspects of smartphone EMA. Discussion: Overall, smartphone EMA was deemed as being an acceptable method for monitoring pain and symptoms associated with knee OA. These findings will assist researchers in designing future EMA studies alongside clinicians implementing smartphone EMA into practice. Perspective: This study highlights that smartphone EMA is an acceptable method for capturing pain-related symptoms and experiences of those expereiencing knee OA. Future EMA studies should ensure design features are considered that reduce missing data and limit the responder burden to improve data quality.
The Journal of Pain, Apr 1, 2017
Clinical pain conditions disproportionately affect women. Moreover, up to 70% of obese adults in ... more Clinical pain conditions disproportionately affect women. Moreover, up to 70% of obese adults in the U.S. report chronic musculoskeletal pain. The current study examined whether sex moderated the association between Body Mass Index (BMI), pain, functional, and psychosocial outcomes in a sample of individuals with chronic low back pain (CLPB). Participants included 75 men (Mean age = 43, SD = 12.3) and 67 women (Mean Age = 39.38, SD = 12.23). Male and female participants did not differ in age, pain duration, or BMI (BMI = 28.87 and 29.28, respectively). Higher BMI was associated with greater self-reported pain in female but not male participants, representing a marginal moderation effect of sex (B=.44, p=.06). Sex was found to moderate the association between BMI and participants' self-reported disability (B=.28, p<.05) and depression (B=.44, p<.01) in that higher BMI was associated with greater disability and depression in female but not male participants. Sex significantly moderated the association between BMI and both anticipated and experienced pain in response to standardized laboratory tasks (B=.11, B=.12, p<.05, respectively), in that higher BMI was associated with higher pain ratings only among female participants. Findings from the current study suggest that sex influences the relationship between body composition, pain, disability, and psychological outcomes. Understanding sex differences in these relationships may better guide evaluation and treatment strategies for CLBP.
Frontiers in pain research, Jan 13, 2023
Knee Osteoarthritis (OA) is a prevalent musculoskeletal condition, commonly resulting in pain and... more Knee Osteoarthritis (OA) is a prevalent musculoskeletal condition, commonly resulting in pain and disability. However, pain and disability in this population are poorly related with the degree of structural joint damage. Underlying pain mechanisms, including activity-related pain and sensitization assessed via Quantitative Sensory Testing (QST), may better predict pain and functional outcomes of those with knee OA. Therefore, the aim of this study was to explore whether activity-related pain and sensitization assessed via QST predict future pain, function, fatigue, physical performance and quality of life outcomes in those living in the community with knee OA. Eighty-six participants with knee OA were recruited in Dunedin, New Zealand. Those eligible to participate underwent baseline testing including QST as well as measures of activity-related pain including Movement-evoked Pain (MEP) and Sensitivity to Physical Activity (SPA). Outcome measures exploring pain, function, fatigue and quality of life outcomes were collected at baseline, and two follow-up periods (two and nine weeks). Univariable linear regression models were developed followed by multivariable linear regression models for each prognostic marker adjusting for age, gender, BMI, OA duration, baseline pain intensity and socioeconomic status. Activityrelated measures of pain, including MEP and SPA, demonstrated predictive associations with pain and functional outcomes prospectively in those with knee OA. Therefore, those demonstrating activity-related pain are at future risk of greater pain, disability and reduced quality of life. Larger, externally validated longitudinal studies are required which include individuals with more severe knee OA.
Disability and Rehabilitation, Feb 4, 2021
PURPOSE Stroke can cause lifelong disability and participatory limitations. Stroke survivors thus... more PURPOSE Stroke can cause lifelong disability and participatory limitations. Stroke survivors thus manage their recovery long term. Health professionals can support self-management, tailoring this support to be culturally appropriate. This study explored the unique culture and ethnicity specific experiences of Indian people living in New Zealand with stroke, focussing on self-management and facilitators and challenges to recovery. METHODS Eight individuals with stroke took part in semi-structured interviews. Data were analysed using the General Inductive Approach. RESULTS Four themes were identified: (1) helping myself, in any way that I can, (2) family and support, (3) social connections, and (4) ethnicity was not a barrier. CONCLUSION All participants felt well looked after within the New Zealand healthcare context but highlighted the need for long term support. Self-management strategies participants considered important included changes to their diet, acceptance by oneself and society, returning to work, the role of family, and the use of technology and social media. Health professionals should consider these factors when providing self-management support to individuals of Indian ethnicity. IMPLICATIONS FOR REHABILITATION Advice and help around diet, lifestyle, and return to work were important priorities identified by our Indian stroke survivor participants. Our Indian stroke survivor participants requested more long-term specialist support and stroke information. Although the family willingly take increased responsibility for the wellbeing of the individual with stroke, it is not a substitute for professional input which needs to be tailored and offered proactively.
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Papers by RAMAKRISHNAN MANI