RAMAKRISHNAN MANI
University of Otago, School of Physiotherapy, Faculty Member
- My research aims to elucidate the role of cortical, nociplastic and psychosocial mechanisms/risk factors on pain expe... moreMy research aims to elucidate the role of cortical, nociplastic and psychosocial mechanisms/risk factors on pain experience and test self-regulatory interventions targeting mechanisms to improve clinical outcomes in people with chronic pain. Current projects: 1. Mindfulness Meditation and Neurofeedback training for people with chronic MSK pain. 2. Dunedin Study: Role of early biopsychosocial exposures on adult pain experience. 3. Translating Pain Sensitivity Knowledge into Clinical Practiceedit
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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... 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.
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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,... 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.
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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.... 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.
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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... 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.
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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... 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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Assessment of control of posture using a task battery that represents work-related postural conditions is highly recommended for providing a comprehensive understanding of collective postural demands. However, dearth of evidence exists on... more
Assessment of control of posture using a task battery that represents work-related postural conditions is highly recommended for providing a comprehensive understanding of collective postural demands. However, dearth of evidence exists on the reliability of a task battery, thus precluding its use as an outcome measure in field research. This study investigated the intrasession reliability and systematic variation of force plate derived centre of pressure (COP) measures obtained during repeated performance of a task battery (lifting task, limits of stability and bipedal and unipedal stance). COP signals obtained during each task performance were processed to derive various time-domain COP measures. Statistical analyses revealed that 13 of the 19 COP measures displayed excellent relative (ICC(2,3) ≥ 0.75) and acceptable absolute reliability (SEM%: ≤ 10). Although COP measures displayed systematic variation, the differences were less or equal to the measurement error, except COP measures of unipedal stance and limits of stability. The chosen task battery is reliable and can be used for comprehensive evaluation of control of posture, in both field and laboratory research. Practitioner Summary: Repeated evaluation of multiple tasks together sequentially could introduce measurement variability. This study investigated intrasession reliability of a task battery representing common work-related postures. The chosen task battery was found to be reliable with acceptable measurement error and can be used in field research settings for evaluation of control of posture.
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Brisk walking is the most popular activity for obesity management for adults. We aimed to identify whether participant age, sex and body mass index (BMI) influenced the effectiveness of brisk walking. A search of nine databases was... more
Brisk walking is the most popular activity for obesity management for adults. We aimed to identify whether participant age, sex and body mass index (BMI) influenced the effectiveness of brisk walking. A search of nine databases was conducted for randomized controlled trials (RCTs). Two investigators selected RCTs reporting on change in body weight, BMI, waist circumference, fat mass, fat-free mass, and body fat percentage following a brisk walking intervention in obese adults. Of the 5,072 studies screened, 22 met the eligibility criteria. The pooled mean differences were: weight loss -2.13 kg; BMI -0.96 kg/m2; waist circumference -2.83 cm; fat mass -2.59 kg; fat-free mass 0.29 kg; and, body fat percentage -1.38%. Meta-regression of baseline BMI showed no effect on changes. Brisk walking can create a clinically significant reduction in body weight, BMI, waist circumference and fat mass for obese men and women aged under 50 years. Obese women aged over 50 years can achieve modest losses, but gains in fat-free mass reduce overall change in body weight. Further research is required for men aged over 50 years and on the influence of BMI for all ages and sexes.
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Cervicobrachial pain syndrome (CBPS) can be characterized by enhanced mechanosensitivity of the neural tissues that can be tested and treated using asymptomatic arm in patients with irritable symptom. The study aimed at examining the... more
Cervicobrachial pain syndrome (CBPS) can be characterized by enhanced mechanosensitivity of the neural tissues that can be tested and treated using asymptomatic arm in patients with irritable symptom. The study aimed at examining the effect of asymptomatic arm neural mobilization on elbow extension, pain intensity and disability in patients with unilateral CBPS. Ten patients with mean age of 30.40±10.07 met the eligibility criteria. NPRS and DASH questionnaire were administered at baseline. ULNT1 was performed on symptomatic arm and elbow extension to the point of first pain was noted (P1). Holding symptomatic arm position, ULNT1 was performed on asymptomatic arm and change in symptomatic arm elbow extension was measured (P1c). Six sessions of neural mobilization were administered on asymptomatic arm for six consecutive days and change in symptomatic arm elbow extension was measured everyday (P1m). NPRS and DASH questionnaire re-administered at the end of sixth session. All the patients showed a significant improvement in elbow extension (P1- P1c p<0.001 and P1- P1m p<0.001) and a significant decrease in pain (NPRS p=0.005) and disability (DASH p=0.012). The findings of the study can be used to form the basis of future studies.
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Background: The incidence and severity of phantom limb pain (PLP) does not differ much between the extremities of amputation. However, its impact on functional ability and quality of life in lower limb amputation may be different, as... more
Background: The incidence and severity of phantom limb pain (PLP) does not differ much between the extremities of amputation. However, its impact on functional ability and quality of life in lower limb amputation may be different, as prosthetic weight bearing is a key component in the movement and functional rehabilitation of individuals with a lower limb amputation. Objective: To evaluate the evidence for effectiveness or efficacy of non-pharmacological interventions in the management of PLP in adults with lower limb amputation. Methods: A comprehensive literature search conducted on 11 electronic databases, from their inception to 25 March 2016 identified 626 potentially relevant articles. Full-text randomised controlled trials in English which examined any form of non-pharmacologic intervention for managing PLP in lower limb amputees were included. The data with regard to characteristics of the studies, participants, intervention and outcome measures and overall statistical result were extracted. The Cochrane ‘Risk of bias assessment tool’ was used to assess the bias of all included articles. Results: Four studies met the final criteria to be included in the review. Four treatment techniques had been used in the treatment of 204 patients with lower limb amputation. Two trials showed a positive impact of intervention on PLP compared to control group. Risk of bias varied across studies, and only one included study was assessed as having a low risk of bias. Conclusion: The review identified lack of evidence to support non-pharmacological interventions in the management of PLP. Adequately powered high-quality trials are needed in this area to inform rehabilitation.
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Two-point discrimination threshold (TPDT) is increased in individuals with chronic low back pain. TPDT reference values and their determinants are required for clinical applications. Therefore, the aims of this research are to establish... more
Two-point discrimination threshold (TPDT) is increased in individuals with chronic low back pain. TPDT reference values and their determinants are required for clinical applications. Therefore, the aims of this research are to establish reference values for TPDT of the low back regions in healthy individuals, stratified for age, and to investigate the associations of demographic and anthropomorphic variables with TPDT. Healthy individuals (n = 79) across four decades (Group-I:18-29; Group-II:30-39; Group-III:40-49; and Group-IV:50-59years) were recruited. A mechanical calliper tool was used to determine the low back TPDT (mm) using an adaptive staircase method. Descriptive statistics were calculated for TPDT for each age group. Paired t-tests (p ≤ 0.05) were used to assess within group differences in TPDT between body sides. Univariate and weighted least squared linear regression analyses were performed to investigate associations between TPDT estimates and demographics, and body mass index (BMI), waist hip ratio (WHR). Mean (SD) age = 38.3(12.2); 55 female; and 73 right lower limb dominant. Mean (SD) TPDT threshold for all age groups: right = 67.3(15.6), and left = 65.7(15.4). No significant differences between left and right sides of the low back except in group-IV (mean difference:5.6[0.7-10.5]; P = 0.028). A total of 18% of TPDT variance (adjusted R(2) = 0.183; β = 0.6; p = ≤0.001) of low back regions was explained by age with BMI and WHR weighted independently. Age, BMI, and WHR were independently associated with TPDT of the low back, and the influence of age was significantly influenced by obesity indices.
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OBJECTIVE The purpose of the present study was to determine the neuroendocrine response after a thoracic spinal manipulation in people with Achilles tendinopathy. METHODS This was a randomized 2-sequence, 2-period crossover trial. A total... more
OBJECTIVE The purpose of the present study was to determine the neuroendocrine response after a thoracic spinal manipulation in people with Achilles tendinopathy. METHODS This was a randomized 2-sequence, 2-period crossover trial. A total of 24 participants, mean (standard deviation) age of 48 (7) years, with a diagnosis of Achilles tendinopathy (>3 mo) were randomly assigned into sequence 1 (sham intervention and then thoracic spinal manipulation) or sequence 2 (thoracic spinal manipulation and then sham intervention). The trial was conducted at a university laboratory with a washout period of 1 week. The primary outcome measure was the testosterone/cortisol (T/C) ratio (salivary samples). The secondary outcome measures included heart rate variability (measured with electrocardiography) and total oxygenation index (nmol/L) of calf muscle and Achilles tendon (measured with near-infrared spectroscopy). A 2-way mixed-model analysis of variance was performed. The statistic of interest was the condition by time interaction. RESULTS A statistically significant condition by time interaction was found for the T/C ratio (mean difference: -0.16; confidence interval: -0.33 to 0.006; interaction: P < .05) and the total oxygenation index (mean difference: 1.35; confidence interval: -1.3 to 4.1; interaction: P < .05) of calf muscle but not for Achilles tendon (P = .6); however, no difference was found for heart rate variability (P = .5). CONCLUSION In people with Achilles tendinopathy, thoracic spinal manipulation resulted in immediate increase in the total oxygenation index in the calf muscle followed by an increase in the T/C ratio 6 hours post-intervention.
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BACKGROUND AND AIMS Alterations in central somatosensory function (e.g. cortical reorganisation) occurs secondary to chronic knee pain. The reorganization can be quantified using a clinical signatory measure, the two-point discrimination... more
BACKGROUND AND AIMS Alterations in central somatosensory function (e.g. cortical reorganisation) occurs secondary to chronic knee pain. The reorganization can be quantified using a clinical signatory measure, the two-point discrimination threshold (TPDT). In order to differentiate normal variability of TPDT against abnormal thresholds for clinical practice, development of body region specific reference values are required and the factors that determine the TPDT have to be established. OBJECTIVE To establish reference values for TPDT of the knee region in healthy individuals and to determine the factors that influence the TPDT of the knee regions. METHODS Participants across four decades (18-59 years; n = 79) were recruited. TPDT estimates for medial and lateral knee regions were determined using a mechanical calliper. Descriptive statistics, and linear regression analyses were performed to establish reference TPDT values, and to investigate associations between demographics, anthropometric variables, and TPDT estimates respectively. RESULTS Participants' Mean (SD) age = 38.3 (12.2); females (n = 56); and right lower limb dominant (n = 72). Mean TPDT threshold ranges included: lateral right knee, 36.7 (14.3); medial right knee, 28.6 (9.7); lateral left knee, 37.7 (12.9); and medial left knee, 27.9 (11.4). Fifteen percent of the threshold variance (R2 = 0.148) of TPDT estimates was explained by the medial aspect (β = -8.9; p = 0.000) and male gender (β = 3.1; p = 0.057), weighted by anthropometric factors. CONCLUSIONS Age-stratified knee TPDT estimates have been reported to aid clinical interpretation. Regional asymmetry, gender, and obesity indices are factors that determine the TPDT of the knee. Normal TPDT asymmetry observed at medial aspect of the knee has significantly greater acuity compared to the lateral knee.
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Background: The coronavirus-19 (COVID-19) pandemic has affected millions of people across the world since early 2020. Besides the large number of case fatalities, this virus has produced significant health-related sequelae involving... more
Background: The coronavirus-19 (COVID-19) pandemic has affected millions of people across the world since early 2020. Besides the large number of case fatalities, this virus has produced significant health-related sequelae involving multiple systems of the body. As with previous coronavirus infections, this was also found to be associated with various neuropsychiatric symptoms. Psychosis has been uncommon, and the few reported cases across the world have forwarded association with either raised inflammatory markers or the consequences of social isolation. Materials and Methods: This is a retrospective descriptive study of 12 patients, who were admitted with COVID-19 infection and psychosis, between March 2020 and December 2020. Cases of head injury, any neurological or metabolic illnesses, and substance use disorders were excluded. Results: Cases with psychosis formed only 0.19% of all cases of COVID-19 admissions. All of them were young male and employed. Most of them had abrupt onset of psychosis with confusion, delusions, hallucinations, agitation, and sleep disturbances. Investigations including inflammatory markers (C-reactive protein) and computerized tomography scans were largely normal. Medications used were mainly benzodiazepines and antipsychotics. Most of the cases resolved within the second week, and follow-up after a month did not elicit any residual symptoms in majority. Diagnosis was acute and transient psychotic disorder (about 75%), bipolar affective disorder (2 cases), and schizophrenia (one). Conclusions: The major findings included nonreactive inflammatory markers, quick resolution of symptoms, requirement of low doses of antipsychotic drugs, and no long-term sequelae.