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Are You Sure It’s 10 Out of 10?What To Do When Pain is Paradoxical
Presented by:
Zachary Stearns, PT, DPT
Board-Certified Orthopaedic Clinical Specialist
PhD student (Health Sciences):
Rocky Mountain University of Health
ProfessionsTwitter: @zachrstearns
Who Is Here?
• Clinicians?
– Outpatient vs. Inpatient vs. Home health
• Students?
• Academic?
• Managerial/administrative?
• Patients/Patient advocates?
• Other?
When Pain is Paradoxical
• Recall a time when…– Someone’s pain made
no sense to you
– OR when you doubted the reality of pain
– OR when you thought someone was exaggerating pain
• For this presentation, that person is your person in pain
My “Person In Pain”: The First Patient On My Schedule
• MVA 2 weeks prior to evaluation
• Two small children in the car (uninjured)
• Other vehicle rolled over, totaled
• Unremarkable radiographs in ED
• Pain “jumped” from entire leg to leg, at rest
• Aggravated by bending, prolonged
positioning
Your Person In Pain:
What is their story?
What sticks with you about that story?
What confused you?
“To have great pain is to have certainty;
to hear that another person has pain is to have doubt.”
–Elaine Scarry,
The Body In Pain
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Objectives
• Attendees will be able to:
– Identify the domains of the pain experience that may serve as primary drivers of pain.
– Describe a clinical model that promotes pattern recognition to aid the diagnosis and treatment of pain.
– Discuss strategies of narrative-based medicine that improve the understanding of the pain experience and strengthen the therapeutic alliance.
– Compare the benefits of evidence-based pain management with the benefits of narrative-based practice.
Objectives
• Attendees will be able to:
– Identify the domains of the pain experience that may serve as primary drivers of pain.
– Describe a clinical model that promotes pattern recognition to aid the diagnosis and treatment of pain.
– Discuss strategies of narrative-based medicine that improve the understanding of the pain experience and strengthen the therapeutic alliance.
– Compare the benefits of evidence-based pain management with the benefits of narrative-based practice.
Pain Mechanisms
Chimenti et al. 2018; Smart et al.
2012a-c
Pain #2
Pain #3Pain #1
Pain Mechanisms
Chimenti et al. 2018; Smart et al.
2012a-c
Pain #2
Pain #3
Photo by Jesper Aggergaard on Unsplash
Nociceptive
Due to activation of
nociceptors
• Inflammation
• Mechanical
irritant
• Injury
• Ex. Ankle sprain
Nociceptive pain
• Cluster found to have high levels of
classification accuracy (Sn 90.9%, Sp 91.0%)
– Pain localized to the area of dysfunction
– Proportionate mechanical nature to aggravating
and alleviating factors
– Intermittent and sharp with mechanical
provocation; may be a dull ache or throb at rest
– Absence of pain described as burning, shooting,
sharp or electric-shock-like
Smart et al. 2012
Nociceptive Nociceptive pain Nociceptive
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Nociceptive
Nociceptive pain
Chimenti et al. 2018; Smart et al. 2012a-c
Due to activation of
nociceptors
• Inflammation
• Mechanical
irritant
• Injury
• Ex. Ankle sprain
Photo by Mitchell Hollander on Unsplash
Persistent pain
can be
nociceptive
Nociceptive
Due to activation of
nociceptors
• Inflammation
• Mechanical
irritant
• Injury
• Ex. Ankle sprain
“Nociception is neither
sufficient nor necessary for
pain.”
Moseley & Vlaeyen, 2015
• Cluster found to have high levels of
classification accuracy (Sn 90.9%, Sp 91.0%)
– Pain localized to the area of dysfunction
– Proportionate mechanical nature to aggravating
and alleviating factors
– Intermittent and sharp with mechanical
provocation; may be a dull ache or throb at rest
– Absence of pain described as burning, shooting,
sharp or electric-shock-like
Smart et al. 2012
Nociceptive
Nociceptive
Pain Mechanisms
Chimenti et al. 2018; Smart et al.
2012a-c
Pain #3
Due to activation of
nociceptors
• Inflammation
• Mechanical
irritant
• Injury
• Ex. Ankle sprain
Flame Photo by Yaoqi LAI on UnsplashLightning Photo by Brandon Morgan on Unsplash Icicle Photo by Robert Zunikoff on Unsplash
Neuropathic
Due to lesion or
disease of
somatosensory
system
• Ex. Complex
regional pain
syndrome
Neuropathic pain assessment
• Observation and touch to assess color
changes, allodynia, or hyperalgesia
• Neural tension testing
• PainDETECT Questionnaire
– https://tinyurl.com/y5hd4y4p
Neuropathic
• Cluster found to have high levels of
classification accuracy (Sn 86.3%, Sp 96.0%)
– Pain referred in a dermatomal or cutaneous nerve
distribution
– History of nerve injury, pathology, or mechanical
compromise
– Pain/symptom provocation with
mechanical/movement tests (e.g. Active/passive,
Neurodynamic) that move/load/compress neural
tissue
Smart et al. 2012
Neuropathic
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Two mechanisms of neuropathic pain
Lundy-Ekman 2013
Neuropathic
Unlike nociceptive pain, neuropathic pain does not require transduction (i.e., the conversion of noxious stimulus to nociceptive impulse)
Cohen & Mao, 2014
Neuropathic
Example: Complex Regional Pain Syndrome
Current IASP Clinical Diagnostic Criteria
1. Continuing pain, disproportionate to any inciting event
2. One symptom in 3 out of 4 categories:• (Sensory): hyperalgesia or allodynia or both
• (Vasomotor): temperature asymmetry or skin color changes/asymmetry
• (Sudomotor/edema): edema or sweating changes/asymmetry
• (Motor/trophic): decreased range of motion ormotor dysfunction or trophic changes (hair, nails, skin)
Bruehl, 2015
Example: Complex Regional Pain Syndrome
Current IASP Clinical Diagnostic Criteria
3. One sign at evaluation in 2 or more
categories:
• (Sensory): Evidence of hyperalgesia or allodynia
• (Vasomotor): Evidence of temperature asymmetry
or skin color changes/asymmetry
• (Sudomotor/edema): Evidence of edema or
sweating changes/asymmetry
• (Motor/trophic): Evidence of decreased range of
motion or motor dysfunction or trophic changes
4. No other diagnosis explains these better
Bruehl, 2015
A treatment: Graded Motor Imagery
Example: Complex Regional Pain Syndrome
Laterality
Training
Explicit
Imagery
Mirror
Therapy
Noigroup, 2016; Moseley 2004
Neuropathic
Neuropathic pain does not require discrete
large nerve injury
23% of those with hip/knee osteoarthritis
have neuropathic pain (95% CI: 10%-39%)
(French et al., 2017)
Neuropathic
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Pain Mechanisms
Nociceptive
NeuropathicDue to activation of
nociceptors
• Inflammation
• Mechanical
irritant
• Injury
• Ex. Ankle sprain
Due to lesion or
disease of
somatosensory
system
• Ex. Complex
regional pain
syndrome
Due to
disturbance in
central pain
processing.
• Ex.
Fibromyalgia
Chimenti et al. 2018; Smart et al.
2012a-c
Nociplastic
NociplasticIASP Definition:
Pain that arises from altered
nociception despite no clear evidence
of actual or threatened tissue damage
causing the activation of peripheral
nociceptors or evidence for disease or
lesion of the somatosensory system
causing the pain.
IASP Definition, paraphrased:
Pain that arises from altered nociception despite
no clear evidence of noxious stimulus causing
nociceptive pain or evidence for neuropathic
pain.IASP 2018; Aydede & Shriver, 2018
Nociplastic
IASP 2018; Aydede & Shriver, 2018
IASP Definition:
Pain that arises from altered
nociception despite no clear evidence
of actual or threatened tissue damage
causing the activation of peripheral
nociceptors or evidence for disease or
lesion of the somatosensory system
causing the pain.
A proposed revision of the definition:
Pain that arises from altered nociceptive function
Chimenti et al. 2018
Nociplastic
No pain
Peripheral
sensitization
Central
sensitization
Peripheral and
Central sensitization
Central Sensitization
• Symptoms and Signs Cluster (Sn 91.8%, Sp97.7%– Pain disproportionate to nature and extent of
injury and pathology
– Non-mechanical, unpredictable, disproportionate patterns of pain provocation in response to non-specific aggravating/easing factors
– Diffuse areas of pain/tenderness on palpation
– Strong association with maladaptive psychosocial factors (negative emotions, poor self-efficacy, maladaptive beliefs and pain behaviors, altered family/work/social life, medical conflict)
Smart et al. 2012
Nociplastic Nociplastic
Chimenti et al. 2018
Conditioned Pain
Modulation is
impaired in people
with fibromyalgia and
widespread pain
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Boissoneault et al. 2019
NociplasticCortical Differences
Boissoneault et al. 2019
NociplasticCortical Differences
Objectives
• Attendees will be able to:
– Identify the domains of the pain experience that may serve as primary drivers of pain.
– Describe a clinical model that promotes pattern recognition to aid the diagnosis and treatment of pain.
– Discuss strategies of narrative-based medicine that improve the understanding of the pain experience and strengthen the therapeutic alliance.
– Compare the benefits of evidence-based pain management with the benefits of narrative-based practice.
Objectives
• Attendees will be able to:
– Identify the domains of the pain experience that may serve as primary drivers of pain.
– Describe a clinical model that promotes pattern recognition to aid the diagnosis and treatment of pain.
– Discuss strategies of narrative-based medicine that improve the understanding of the pain experience and strengthen the therapeutic alliance.
– Compare the benefits of evidence-based pain management with the benefits of narrative-based practice.
Clinical Model of Triangulation Elliott & Walton,
2018Socioenvironmental
Cognitive/Belief
Emotional/
Affective
Central Nociplastic Peripheral Neuropathic
Nociceptive /
Physiological
Sensorimotor
Dys-integration
Very
Low
Low
Moderate
High
Very High
Clinical Model of Triangulation
• Nociceptive / Physiological
• Peripheral Neuropathic
• Central Nociplastic
Elliott & Walton,
2018
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Clinical Model of Triangulation
• Nociceptive / Physiological
• Peripheral Neuropathic
• Central Nociplastic
• Emotional/Affective
– Diagnosable psychopathology or affective
dysregulation as per DSM V
– Examples: depression, anxiety, schizophrenia,
or other mood disorder or personality disorder
Elliott & Walton,
2018 Clinical Model of Triangulation
• Emotional/Affective
– Depression and anxiety disorders are the
most common health conditions that co-occur
with pain
– The relationship is bi-directional
– Having a mental health condition increases
the likelihood of future chronic pain
– 40-60% of people with chronic pain have
depression
Elliott & Walton,
2018
Darnall 2019
Clinical Model of Triangulation
• Emotional/Affective
– The Patient Health Questionnaire (PHQ-2)
– A screen for major depression
Over the past 2 weeks, how often have you
been bother by the following problems:
Elliott & Walton,
2018
Not at allSeveral
days
More
than half
the days
Nearly
every day
Little interest or pleasure
in doing things0 1 2 3
Feeling down, depressed,
or hopeless0 1 2 3
(Kroenke et al., 2009)
Clinical Model of Triangulation
• Nociceptive / Physiological
• Peripheral Neuropathic
• Central Nociplastic
• Emotional/Affective
• Maladaptive Cognitions
– Unhelpful thoughts or beliefs related to pain
(yellow flags)
– Examples: fear avoidance, pain
catastrophizing, low self-efficacy
Elliott & Walton,
2018
Clinical Model of Triangulation
• Maladaptive Cognitions
– Pain catastrophizing: “a pattern of negative
cognitive and emotional responses to pain
and includes rumination on pain, the
magnification of pain, and feelings of
helplessness about pain” (Darnall, 2019)
– Catastrophizing increases pain and leads to
brain changes (Hubbard et al., 2014)
– High catastrophizing leads to six times
greater likelihood of adverse outcome for
knee replacements (Riddle et al., 2010)
Elliott & Walton,
2018 Clinical Model of Triangulation
• Maladaptive Cognitions
– Pain-related fear
• Fear of pain predicts new-onset back pain 1 year
after pain-free baseline (Linton et al., 2000)
– Measures:
• Pain Catastrophizing Scale
• Fear Avoidance Beliefs Questionnaire
• Fear of Daily Activities Questionnaire
– Treatment consideration:
• Graded exposure (Darnall, 2019; Zeppieri & George, 2009)
Elliott & Walton,
2018
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Clinical Model of Triangulation
• Nociceptive / Physiological
• Peripheral Neuropathic
• Central Nociplastic
• Emotional/Affective
• Maladaptive Cognitions
• Socioenvironmental Context
– Wide-ranging contextual factors
– Examples: poor access to care; relationships
with family, friends, employer; cultural beliefs
Elliott & Walton,
2018 Clinical Model of Triangulation
• Socioenvironmental Context
– Those with low educational attainment are
three times more likely to develop chronic
post-surgical pain after knee replacement
(95% CI: 1.09-9.93) (Nunez-Cortes et al., 2019)
– Low education and low job position predicted
low back pain six months later (Fliesser et al., 2017)
Elliott & Walton,
2018
Clinical Model of Triangulation
• Nociceptive / Physiological
• Peripheral Neuropathic
• Central Nociplastic
• Emotional/Affective
• Maladaptive Cognitions
• Socioenvironmental Context
• Sensorimotor Dys-Integration
– Discordance between perceived self and
actual self. A problem of interoception.
Elliott & Walton,
2018 Clinical Model of Triangulation
• Sensorimotor Dys-Integration
– Those with neck pain are more likely than
those without pain to show “Joint Position
Sense Error” (de Vries et al., 2015)
– Caution: mechanisms and directionality still
unclear
Elliott & Walton,
2018
Clinical Model of Triangulation
• Nociceptive / Physiological
• Peripheral Neuropathic
• Central Nociplastic
• Emotional/Affective
• Maladaptive Cognitions
• Socioenvironmental Context
• Sensorimotor Dys-Integration
Elliott & Walton,
2018 Clinical Model of TriangulationSocioenvironmental
Cognitive/Belief
Emotional/
Affective
Central Nociplastic Peripheral Neuropathic
Nociceptive /
Physiological
Sensorimotor
Dys-integration
Very
Low
Low
Moderate
High
Very High
Elliott & Walton, 2018
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Purely NociceptiveSocioenvironmental
Cognitive/Belief
Emotional/
Affective
Central Nociplastic Peripheral Neuropathic
Nociceptive /
Physiological
Sensorimotor
Dys-integration
Very
Low
Low
Moderate
High
Very High
Elliott & Walton, 2018A More “Common” Pattern
Socioenvironmental
Cognitive/Belief
Emotional/
Affective
Central Nociplastic Peripheral Neuropathic
Nociceptive /
Physiological
Sensorimotor
Dys-integration
Very
Low
Low
Moderate
High
Very High
Elliott & Walton, 2018
My Person In PainSocioenvironmental
Cognitive/Belief
Emotional/
Affective
Central Nociplastic Peripheral Neuropathic
Nociceptive /
Physiological
Sensorimotor
Dys-integration
Very
Low
Low
Moderate
High
Very High
Elliott & Walton, 2018Your Person In Pain?
Elliott & Walton, 2018
Socioenvironmental
Cognitive/Belief
Emotional/
Affective
Central Nociplastic Peripheral Neuropathic
Nociceptive /
Physiological
Sensorimotor
Dys-integration
Very
Low
Low
Moderate
High
Very High
Objectives
• Attendees will be able to:
– Identify the domains of the pain experience that may serve as primary drivers of pain.
– Describe a clinical model that promotes pattern recognition to aid the diagnosis and treatment of pain.
– Discuss strategies of narrative-based medicine that improve the understanding of the pain experience and strengthen the therapeutic alliance.
– Compare the benefits of evidence-based pain management with the benefits of narrative-based practice.
Objectives
• Attendees will be able to:
– Identify the domains of the pain experience that may serve as primary drivers of pain.
– Describe a clinical model that promotes pattern recognition to aid the diagnosis and treatment of pain.
– Discuss strategies of narrative-based medicine that improve the understanding of the pain experience and strengthen the therapeutic alliance.
– Compare the benefits of evidence-based pain management with the benefits of narrative-based practice.
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Why we need the narrative Why we need the narrative:
“Pain narrative is the most conceptually
aligned with the definition of pain.
“Pain narrative best supports ethical
principles when applied to practice.
“Pain narrative is commonly regarded as a
root source of validity in research and
practice.”
Wideman et al., 2019, p. 215
The Multimodal Assessment Model of Pain
Wideman et al., 2019
The Multimodal Assessment Model of Pain
Wideman et al., 2019
Narrative-based medicine
Definition:
Narrative medicine is medicine practiced with
the competence to recognize, absorb, interpret,
and be moved by the stories of illness.
Charon et al., 2016; Zaharias 2018
Narrative medicine
Attention
Representation
Affiliation
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Narrative medicine
Attention Representation Affiliation
“Absorbing what can be learned about [a]
person’s situation”
“Embracing patients as teachers”
“Becoming a recognizing vessel”
Charon, 2007
Narrative medicine
Attention Representation Affiliation
Making “audible and visible that which
otherwise would pass without notice.”
Telling, writing, drawing, sculpting, singing…
Charon, 2007
Narrative medicine
Attention Representation Affiliation
Charon, 2007
“The authentic and muscular connections
between doctor and patient…”
“To creatively ‘think with stories’ toward
personal and public meaning.”
Strive for therapeutic alliance
Narrative medicine: Close Reading
1. Observation
2. Perspective
3. Form
4. Voice
5. Mood
6. Motion
Charon et al., 2016
Narrative medicine: Close Reading
1. Observation
– Perceiving the concrete details.
– Seeing, hearing, touching.
– Descriptions, sensations.
Charon et al., 2016
Narrative medicine: Close Reading
1. Observation
2. Perspective
– Are there multiple perspectives?
– What are the assumptions, beliefs of the
perspective?
Charon et al., 2016
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Narrative medicine: Close Reading
1. Observation
2. Perspective
3. Form
– What is the genre (e.g., story, cautionary tale,
poem, film)
– Notice metaphor or imagery
– Note the order (e.g., chronological, random)
Charon et al., 2016
Narrative medicine: Close Reading
1. Observation
2. Perspective
3. Form
4. Voice
– First-person, third-person
– Self-aware or not
– Intimate or remote
Charon et al., 2016
Narrative medicine: Close Reading
1. Observation
2. Perspective
3. Form
4. Voice
5. Mood
– Emotions of the teller
– Intended emotions of the reader
Charon et al., 2016
Narrative medicine: Close Reading
1. Observation
2. Perspective
3. Form
4. Voice
5. Mood
6. Motion
– Where does the story move?
– Where does it end?
– Where does it want to go? Charon et al., 2016
Close Reading
1. Observation
2. Perspective
3. Form
4. Voice
5. Mood
6. Motion
Charon et al., 2016
1. Observation
2. Perspective
3. Form
4. Voice
5. Mood
6. Motion
Charon et al., 2016
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What is
happening in
this painting?
How is your
“person in pain”
like this person?
The Old Guitarist, Pablo Picasso, 1903-04
Photo: Christopher Rose, https://www.flickr.com/photos/khowaga/6377179033/in/photostream/, license (CC BY-NC 2.0)
Narrative Medicine Exercises
• Practice close reading of…
– Fiction
– Poetry
– Art
– Music
– Film
• Write, using prompts:
– “What happened during that encounter?”
– “What is that person’s story?”
– “What letter would you write to the person in pain?”
Objectives
• Attendees will be able to:
– Identify the domains of the pain experience that may serve as primary drivers of pain.
– Describe a clinical model that promotes pattern recognition to aid the diagnosis and treatment of pain.
– Discuss strategies of narrative-based medicine that improve the understanding of the pain experience and strengthen the therapeutic alliance.
– Compare the benefits of evidence-based pain management with the benefits of narrative-based practice.
Objectives
• Attendees will be able to:
– Identify the domains of the pain experience that may serve as primary drivers of pain.
– Describe a clinical model that promotes pattern recognition to aid the diagnosis and treatment of pain.
– Discuss strategies of narrative-based medicine that improve the understanding of the pain experience and strengthen the therapeutic alliance.
– Compare the benefits of evidence-based pain management with the benefits of narrative-based practice.
Evidence for Narrative Medicine
• Narrative medicine practices lead to...
– Increased knowledge of patients in settings
such as genetics counseling, fetal cardiology,
surgical training, and primary care
– Increased patient-centered communication
– Increases in empathy
– Increases in reflection on practice
Charon et al., 2016
Explore mechanisms based on narrative
Chimenti et al. 2018
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Plan treatment based on mechanisms
Chimenti et al. 2018
When Narratives Collide
You A Story,
Text, or
Art Form
Stilwell & Harman, 2019
When Narratives Collide
You Your
Person In
Pain
Stilwell & Harman, 2019
When pain is paradoxical…
The sciences teach us about the
mechanisms of pain.
The humanities teach us about the
narrative of pain.
Combined, they teach us about progress
despite the paradox of pain.
When pain is paradoxical… When all else fails…
“The secret of the care of the patient is in
caring for the patient.”
-Francis Peabody, MD
March 19, 1927
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When all else fails…
May persons in pain… attain happiness
May persons in pain… be free from suffering
May persons in pain… never be separated
from joy
May persons in pain… abide in peacefulness
Resources
• Free Articles
– Chimenti 2018, Charon 2007, Charon 2016
• Books
– Principles and Practice of Narrative Medicine
– The Body in Pain Elaine Scarry
– Kitchen Table Wisdom Rachel Naomi Remen
– Explain Pain David Butler / Lorimer Moseley
– Mechanisms and Management of Pain for the
Physical Therapist Kathleen Sluka
Resources
• Podcasts
– Pain Reframed
– Pain Science and Sensibility
– Stories: Moth
– Stories: On Being
• Blogs
– MyCuppaJo.com
– Healthskills by Bronnie Thompson
Resources
• Clinical Tools
– Nocifacts by Melissa Farmer
• (FREE pain education)
– ISPI Free Information
– Matt Dancigers’s Pain Science Binder
– Joe Tatta’s 5 pillars of pain care
• Facebook Groups
– Exploring Pain Science
– Painful Stories (and How to Hear Them)
Thank you!!!
Twitter: @zachrstearns
Email: [email protected]
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• Boissoneault, J., Penza, C. W., George, S. Z., Robinson, M. E., & Bishop, M. D. (2019). Comparison of brain structure between pain-susceptible and asymptomatic individuals following experimental induction of low back pain. Spine J. doi:10.1016/j.spinee.2019.08.015
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• Cohen, S. P., & Mao, J. (2014). Neuropathic pain: mechanisms and their clinical implications. Bmj, 348, f7656. doi:10.1136/bmj.f7656
• de Heer, E. W., Vriezekolk, J. E., & van der Feltz-Cornelis, C. M. (2017). Poor Illness Perceptions Are a Risk Factor for Depressive and Anxious Symptomatology in Fibromyalgia Syndrome: A Longitudinal Cohort Study. Front Psychiatry, 8, 217. doi:10.3389/fpsyt.2017.00217
• de Vries, J., Ischebeck, B. K., Voogt, L. P., van der Geest, J. N., Janssen, M., Frens, M. A., & Kleinrensink, G. J. (2015). Joint position sense error in people with neck
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• Fliesser, M., Huberts, J. D. W., & Wippert, P.-M. (2017). The choice that matters: the relative influence of socioeconomic status indicators on chronic back pain- a longitudinal study. BMC Health Serv Res, 17(800). doi:10.1186/s12913-017-2735-9
• French, H. P., Smart, K. M., & Doyle, F. (2017). Prevalence of neuropathic pain in knee or hip osteoarthritis: A systematic review and meta-analysis. Semin Arthritis
Rheum, 47(1), 1-8. doi:10.1016/j.semarthrit.2017.02.008
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