Publications by authors named "Michael Girdwood"

14 Publications

  • Page 1 of 1

Implicit motor imagery of the foot and hand in people with Achilles tendinopathy: a left right judgement study.

Pain Med 2021 Sep 14. Epub 2021 Sep 14.

La Trobe Sport & Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, Australia.

Objective: To determine if impairment in motor imagery processes is present in Achilles tendinopathy (AT), as demonstrated by a reduced ability to quickly and accurately identify the laterality (left-right judgement) of a pictured limb. Additionally, this study aimed to use a novel data pooling approach to combine data collected at 3 different sites via meta-analytical techniques that allow exploration of heterogeneity.

Design: Multi site case-control study.

Methods: Three independent studies with similar protocols were conducted by separate research groups. Each study-site evaluated left/right judgement performance for images of feet and hands using Recognise© software and compared performance between people with AT and healthy controls. Results from each study-site were independently collated, then combined in a meta-analysis.

Results: 126 participants (40 unilateral, 22 bilateral AT cases, 61 controls) were included. There were no differences between AT cases and controls for hand image accuracy and reaction time. Contrary to the hypothesis, there were no differences in performance between those with AT and controls for foot image reaction time, however there were conflicting findings for foot accuracy, based on four separate analyses. There were no differences between the affected and unaffected sides in people with unilateral AT.

Conclusions: Impairments in motor imagery performance for hands were not found in this study and we found inconsistent results for foot accuracy. This contrasts to studies in persistent pain of limbs, face and knee osteoarthritis, and suggests that differences in pathoaetiology or patient demographics may uniquely influence proprioceptive representation.
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September 2021

The Validity, Reliability, and Responsiveness of the International Hip Outcome Tool-33 (iHOT-33) in Patients With Hip and Groin Pain Treated Without Surgery.

Am J Sports Med 2021 08 15;49(10):2677-2688. Epub 2021 Jul 15.

La Trobe Sport and Exercise Medicine Research Centre, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia.

Background: The International Hip Outcome Tool-33 (iHOT-33) was developed to evaluate patients seeking surgery for hip and/or groin (hip/groin) pain and may not be appropriate for those seeking nonsurgical treatment.

Purpose: To evaluate the psychometric properties of the iHOT-33 total (iHOT-Total) score and all subscale scores in adults with hip/groin pain who were not seeking surgery.

Study Design: Cohort study (diagnosis); Level of evidence, 3.

Methods: Patients with hip/groin pain who were not seeking surgery were recruited from 2 ongoing studies in Australia. Semistructured one-on-one interviews assessed content validity. Construct validity was assessed by testing hypothesized correlations between iHOT-33 and Copenhagen Hip and Groin Outcome Score (HAGOS) subscale scores. Test-retest reliability was assessed in patients not undertaking treatment and who reported "no change" in their Global Rating of Change (GROC) score at 6-month follow-up. Scores were reliable at group and individual levels if intraclass correlation coefficients (ICCs) were ≥0.80 and ≥0.90, respectively. Scores were responsive if Spearman rank correlations (ρ) between the change in the iHOT-33 score and the GROC score were ≥0.40.

Results: In total, 278 patients with hip/groin pain (93 women; mean age, 31 years) and 55 pain-free control participants (14 women; mean age, 29 years) were recruited. The iHOT-33 demonstrated acceptable content validity. Construct validity was acceptable, with all hypothesized strong positive correlations between iHOT-33 and HAGOS subscale scores confirmed ( range, 0.60-0.76; < .001), except for one correlation between the iHOT-Sport and HAGOS-Sport ( = .058; < .001). All scores were reliable at the group level, except for the iHOT-33 job subscale (iHOT-Job) (ICC range, 0.78-0.88 [95% CI, 0.60-0.93]). None of the subscales met the criteria for adequate reliability for use at the individual level (all ICCs <0.90). Minimal detectable change values (group level) ranged from 2.3 to 3.7 (95% CI, 1.7-5.0). All iHOT-33 subscale scores were responsive (ρ range, 0.40-0.58; ≤ .001), except for the iHOT-Job in patients not undertaking treatment (ρ = 0.27; = .001).

Conclusion: All iHOT-33 subscale scores were valid for use in patients with hip/groin pain who were not seeking surgery. Acceptable test-retest reliability was found for all subscale scores at the group level, except the iHOT-Job. All subscale scores, excluding the iHOT-Job, were responsive, regardless of undertaking physical therapist-led treatment or no treatment.
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August 2021

Physical Activity and Investigation With Magnetic Resonance Imaging Partly Explain Variability in the Prevalence of Patellar Tendon Abnormalities: A Systematic Review With Meta-analysis of Imaging Studies in Asymptomatic Individuals.

J Orthop Sports Phys Ther 2021 05 28;51(5):216-231. Epub 2021 Mar 28.

Objective: To estimate the pooled prevalence of, and factors associated with, the presence of patellar tendon abnormalities observed on imaging in people without symptoms.

Design: Systematic review with stratified meta-analysis and meta-regression.

Literature Search: We searched Embase, Scopus, MEDLINE, CINAHL, SPORTDiscus, and Web of Science from 1980 to August 2020.

Study Selection Criteria: We included studies that reported the prevalence of asymptomatic patellar tendon abnormalities on imaging. We excluded studies of participants with current tendon pain, a history of tendon pain, or other systemic conditions.

Data Synthesis: Stratification and meta-regression of studies based on study-level descriptive statistics (mean age, body mass index, proportion of female participants, physical activity participation, imaging modality) were performed using a random-effects model to account for between-study heterogeneity. Risk of bias was assessed using the modified Newcastle-Ottawa scale.

Results: Meta-analysis of 64 studies (7125 limbs from 4616 participants) found significant between-study heterogeneity (I≥90%, <.01), which precluded a summary prevalence estimate. Heterogeneity was partially explained by studies that included participants who were physically active and studies that assessed tendon abnormalities using magnetic resonance imaging compared to ultrasound (<.05). Mean age, body mass index, proportion of female participants, and sample size did not explain the remaining heterogeneity.

Conclusion: There was substantial variability in the reported prevalence of asymptomatic patellar tendon abnormalities. A clear and valid method is needed to assess and report the presence of patellar tendon abnormalities to increase research capacity and establish the clinical value of imaging the patellar tendon. .
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May 2021

Quantifying the Burden of Shoulder and Hip Pain In Water Polo Players Across Different Playing Levels.

Int J Sports Phys Ther 2021 Feb 1;16(1):57-63. Epub 2021 Feb 1.

The University of Melbourne.

Background: Water polo is characterised by unique skills and movements with high demands of both the upper and lower limb. There is growing recognition of the problems of shoulder and hip/groin symptoms in this population.

Purpose: To quantify the prevalence of shoulder and hip/groin pain in water polo players, and to describe how performance and participation were impacted. Secondary aims investigated whether demographic or training variables were associated with levels of symptoms.

Design: In-season, cross-sectional questionnaire study.

Methods: An online questionnaire was distributed to all adult levels of the Australian water polo community. Participants were asked about demographic and playing history, and then specific injury history at both the shoulder and hip/groin. Each respondent completed an Oslo Sports Trauma Research Centre (OSTRC) overuse injury questionnaire for the shoulder and hip/groin. Point prevalence and past history were calculated, as well as a morbidity score from OSTRC responses. Risk ratios were used to determine differences between playing levels and sex.

Results: One hundred, fifty-three respondents completed the questionnaire (57% female). High rates of shoulder pain were reported (38.1% current, 81.2% past history), as well as hip/groin pain (33.1% current, 60.4% past history). Current shoulder pain was a risk factor for hip/groin pain (RR 1.99 (95%CI 1.27-3.12), and hip/groin pain was a risk factor for shoulder pain (RR 1.70 (95%CI 1.23-2.35). Elite-level athletes had higher prevalence (RR 1.87 [95%CI 1.01-3.46]) and past history of hip/groin pain (RR 1.76 [95%CI 1.32-2.36]).

Conclusions: This is the first study to quantify high self-reported levels of hip/groin pain in water polo athletes. Such high levels may be explained by high amounts of eggbeater kick, especially during skeletal development in adolescence. Shoulder pain continues to be the most common source of injury burden in water polo. Future research should determine whether any modifiable risk factors exist that may reduce the burden of injury in this population.

Level Of Evidence: 2b.
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February 2021

Does isometric exercise result in exercise induced hypoalgesia in people with local musculoskeletal pain? A systematic review.

Phys Ther Sport 2021 May 19;49:51-61. Epub 2020 Sep 19.

La Trobe Sports and Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia. Electronic address:

Objective: The aim of this review was to investigate if exercise induced hypoalgesia (EIH) occurs following isometric muscle contraction in people with local musculoskeletal symptoms.

Design: Systematic review.

Data Sources: MEDLINE, EMBASE, CINAHL & SportDiscus electronic databases were searched (inception to April 2020).

Eligibility Criteria: Two authors independently evaluated eligibility. Randomised controlled and crossover (repeated measures) trials that measured the effects of isometric exercise in participants with localised musculoskeletal pain during, and up to 2 hours after isometric exercise were included. Other inclusion criteria included comparison to another intervention, or comparison to healthy controls. Primary outcomes were experimentally induced pain thresholds and secondary outcomes included measures of pain sensitivity from clinical testing.

Results: 13 studies with data from 346 participants were included for narrative synthesis. EIH was reported in some upper and lower limb studies but there were no consistent data to show isometric exercises were superior to comparison interventions.

Conclusion: There was no consistent evidence for EIH following isometric exercise in people with musculoskeletal pain. These findings are different to those reported in asymptomatic populations (where EIH is consistently demonstrated) as well as conditions associated with widespread symptoms such as fibromyalgia (where isometric exercise may induce hyperalgesia). Although well tolerated when prescribed, isometric exercise did not induce EIH consistently for people seeking care for local musculoskeletal symptoms. The variance in the dose, location of contraction and intensity of protocols included in this review may explain the inconsistent findings. Further work is required to better understand endogenous analgesia in musculoskeletal pain conditions.
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May 2021

Sensory Processing in People With and Without Tendinopathy: A Systematic Review With Meta-analysis of Local, Regional, and Remote Sites in Upper- and Lower-Limb Conditions.

J Orthop Sports Phys Ther 2021 01;51(1):12-26

Objective: To synthesize results of somatosensory processing tests in people with upper- and lower-limb tendinopathy, compared to controls.

Design: Systematic review with meta-analysis.

Literature Search: Four electronic databases (MEDLINE, CINAHL Plus, SPORTDiscus, and Embase) were searched.

Study Selection Criteria: Included studies measured a domain of sensory processing and compared a tendinopathy group to a healthy control group.

Data Synthesis: Meta-analysis was conducted for outcomes with homogeneous data from at least 2 studies. Upper- and lower-limb conditions were compared and outcomes were examined by measurement site (local, regional, or remote to location of pain).

Results: Of the 30 studies included, 18 investigated lateral elbow tendinopathy. The most commonly assessed outcome measures were pressure pain threshold (PPT) and thermal pain threshold. There was moderate evidence for local and regional reduction of PPT in upper-limb tendinopathies, but not at remote sites. In lower-limb tendinopathies, there was conflicting evidence regarding reduced PPT at local sites and limited evidence of normal PPT at remote sites. There was moderate evidence of sensitization of thermal pain threshold at local sites in upper-limb tendinopathies and limited evidence of no difference in thermal pain threshold in lower-limb tendinopathies. Findings across other domains were variable.

Conclusion: Sensory processing was different between upper-limb tendinopathy and lower-limb tendinopathy. Upper-limb tendinopathies showed signs consistent with primary and secondary hyperalgesia, but lower-limb tendinopathies did not. There was mixed evidence for primary hyperalgesia and limited evidence against secondary hyperalgesia. .
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January 2021

ICON PART-T 2019-International Scientific Tendinopathy Symposium Consensus: recommended standards for reporting participant characteristics in tendinopathy research (PART-T).

Br J Sports Med 2020 Jun 13;54(11):627-630. Epub 2019 Sep 13.

Department of Sport and Exercise Medicine, University of Groningen, Groningen, The Netherlands.

We aimed to establish consensus for reporting recommendations relating to participant characteristics in tendon research. A scoping literature review of tendinopathy studies (Achilles, patellar, hamstring, gluteal and elbow) was followed by an online survey and face-to-face consensus meeting with expert healthcare professionals (HCPs) at the International Scientific Tendon Symposium, Groningen 2018. We reviewed 263 papers to form statements for consensus and invited 30 HCPs from different disciplines and geographical locations; 28 completed the survey and 15 attended the meeting. There was consensus that the following data should be reported for cases and controls: sex, age, standing height, body mass, history of tendinopathy, whether imaging was used to confirm pathology, loading tests, pain location, symptom duration and severity, level of disability, comorbidities, physical activity level, recruitment source and strategies, and medication use history. Standardised reporting of participant characteristics aims to benefit patients and clinicians by guiding researchers in the conduct of their studies. We provide free resources to facilitate researchers adopting our recommendations.
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June 2020

Prevalence and factors associated with asymptomatic Achilles tendon pathology in male distance runners.

Phys Ther Sport 2019 Sep 17;39:64-68. Epub 2019 Jun 17.

Deakin University, Centre for Sport Research, School of Exercise and Nutrition Sciences, Melbourne, Australia; Auckland University of Technology, Sport Performance Research Institute New Zealand, Auckland, New Zealand. Electronic address:

Objectives: This study investigated the prevalence of tendon pathology and associated factors in experienced, high mileage male endurance runners with no history of Achilles tendon pain.

Design: Cross-sectional study.

Setting: Achilles tendinopathy is a debilitating running injury affecting 50% of distance runners over their lifetime. It is diagnosed through a clinical examination and imaging, usually grey scale ultrasound (US) imaging. US imaging studies have shown that pathological changes can occur in asymptomatic individuals with no tendon pain.

Participants: Thirty seven male runners who had never had Achilles tendon pain.

Main Outcome Measures: Participants completed a running history survey, had their height, body mass, waist circumference, and ankle dorsiflexion range of movement (ROM) measured, and their tendons were assessed (normal, abnormal) using US imaging.

Results: Almost half (46%) of these asymptomatic distance runners had at least one abnormal tendon. The runners with tendon pathology had significantly (p = 0.024) more years of running training (abnormal: median 20 years, interquartile range 6-25.5) than runners with no pathology (normal: median 7 years, interquartile range 5-15). No other significant differences between the groups were identified.

Conclusions: Asymptomatic male distance runners had a high incidence of tendon pathology. Increased running years was associated with pathology in the Achilles tendon...
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September 2019

Isometric Exercise to Reduce Pain in Patellar Tendinopathy In-Season: Is It Effective "on the Road"?

Clin J Sport Med 2019 05;29(3):188-192

The Australian Collaboration for Research in Injury and Its Prevention (ACRISP), La Trobe University, Bundoora VIC, Australia.

Objective: To investigate the effectiveness of an isometric squat exercise using a portable belt, on patellar tendon pain and function, in athletes during their competitive season.

Design: Case series with no requirements to change any aspect of games or training. The object of this pragmatic study was to investigate this intervention in addition to "usual management." A control or sham intervention was considered unacceptable to teams.

Setting: In-season.

Participants: A total of 25 male and female elite and subelite athletes from 5 sports.

Intervention: 5 × 30-second isometric quadriceps squat exercise using a rigid belt completed over a 4-week period.

Main Outcome Measures: (1) single-leg decline squat (SLDS)-a pain provocation test for the patellar tendon (numerical rating score of pain between 0 and 10), (2) VISA-P questionnaire assessing patellar tendon pain and function, and (3) self-reported adherence with completing the exercise over a 4-week period.

Results: Baseline SLDS pain was high for these in-season athletes, median 7.5/10 (range 3.5-9) and was significantly reduced over the 4-week intervention (P < 0.001, ES r = 0.580, median change 3.5). VISA-P scores improved after intervention (P < 0.001, ES r = 0.568, mean change 12.2 ± 8.9, percentage mean change 18.8%, where minimum clinical important difference of relative change for VISA-P is 15.4%-27%). Adherence was high; athletes reported completing the exercise 5 times per week.

Conclusions: This pragmatic study suggests that a portable isometric squat reduced pain in-season for athletes with patellar tendinopathy (PT). This form of treatment may be effective, but clinical trials with a control group are needed to confirm the results.
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May 2019

Extracorporeal Shock Wave Therapy Immediately Affects Achilles Tendon Structure and Widespread Pressure Pain Thresholds in Healthy People: A Repeated-Measures Observational Study.

Am J Phys Med Rehabil 2019 09;98(9):806-810

From the Chinese University of Hong Kong, Pond Cres, Ma Liu Shui, Hong Kong (HTL); and La Trobe Sport & Exercise Medicine Research Centre, La Trobe University, Bundoora, Victoria, Australia (SD, MG, CB, JC, ER).

Objective: Extracorporeal shockwave therapy is a common clinical treatment for tendinopathy, yet negative effects on tendon structure have been shown in animal studies. This study aimed to investigate the effect of extracorporeal shockwave therapy in healthy participants (i.e., no Achilles tendon pain or pathology).

Design: This study examined the effect of three bouts of weekly extracorporeal shockwave therapy for 3 wks in 13 healthy participants. Outcomes measures assessed were as follows: (a) Achilles tendon structure, quantified using ultrasound tissue characterization (before and 3 hrs after extracorporeal shockwave therapy), (b) pressure pain thresholds, over the Achilles tendon and common extensor tendon origin (before, immediately after, and 3 hrs after extracorporeal shockwave therapy), and (c) hop pain (before and immediately after extracorporeal shockwave therapy).

Results: There was a significant reduction in echo type I (P < 0.05) and increase in echo type II (P < 0.05) at 3 hrs after the first extracorporeal shockwave therapy session that recovered to baseline levels before week 2. There were no significant changes in ultrasound tissue characterization echo pattern observed in subsequent sessions. There were increased pressure pain thresholds immediately after extracorporeal shockwave therapy at the common extensor tendon origin but no significant change at the Achilles tendon. Pressure pain thresholds returned to baseline at 3 hrs after extracorporeal shockwave therapy. There were no significant changes in pressure pain threshold in subsequent sessions.

Conclusions: Extracorporeal shockwave therapy resulted in transient changes to tendon structure and widespread hyperalgesia.
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September 2019

Contact-Related Strain of Quadratus Femoris, Obturator Externus, and Inferior Gemellus in an Australian Football Player: A Case Report.

J Sport Rehabil 2019 Nov;28(8):887-890

Context: Muscle injuries of the hip stabilizers are considered rare in sport.

Objective: This report presents a previously unreported case of a contact injury resulting in acute strain of quadratus femoris, obturator externus, and inferior gemellus in an amateur Australian rules football player.

Design: Level 4-case report.

Case Presentation: A player was tackled ipsilateral to the injured leg, while in hip flexion in a lunged position. The case describes the diagnostic process, initial management, and return to play for this athlete.

Results: Following rehabilitation, the player was able to return to sport at 8 weeks without ongoing issues.

Conclusions: A literature search for sports-related contact injuries to either muscle returned only one result. All other documented cases of injury to these muscle groups are confined to noncontact mechanisms or delayed presentations. Despite conventional teaching, the action of the deep external rotators of the hip appears to be positionally dependent. Knowledge of this type of injury and mechanism may be useful for future clinical reasoning and differential diagnosis in patients with this type of presentation.
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November 2019

Reduced Levels of Aligned Fibrillar Structure Are Not Associated With Achilles and Patellar Tendon Symptoms.

Clin J Sport Med 2020 11;30(6):550-555

La Trobe Sport and Exercise Medicine Research Center, College of Science, Health and Engineering; La Trobe University; Australia; and.

Objective: To investigate whether the mean cross-sectional area (mCSA) of aligned fibrillar structure (AFS) was associated with the presence and severity of symptoms.

Design: Prospective cohort study.

Participants: One hundred seventy-five elite male Australian football players completed monthly Oslo Sports Trauma Research Center overuse injury questionnaires for both the Achilles and patellar tendon over the season to ascertain the presence and severity of symptoms. At the start of the preseason, participants underwent ultrasound tissue characterization (UTC) imaging of the Achilles and patellar tendon.

Main Outcome Measures: Images were classified as normal or abnormal based on gray-scale ultrasound. Based on UTC quantification, the mCSA of AFS was compared between those with and without current symptoms.

Results: No difference in the mCSA of AFS was observed between those with or without tendon symptoms (P < 0.05). Similar to previous findings, 80% to 92% of abnormal tendons had similar amounts of mCSA of AFS compared with normal tendon. If reduced mCSA of AFS was present, it was not associated with the presence or severity of symptoms.

Conclusions: The prevalence, development, or severity of symptoms was not associated with decreased levels of AFS in the Achilles or patellar tendon. This suggests that a lack of structural integrity is not linked to symptoms and questions the rationale behind regenerative medicine. Most tendons are able to compensate for areas of disorganization and maintain tissue homeostasis.
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November 2020

Don't Assume the Control Group Is Normal-People with Asymptomatic Tendon Pathology Have Higher Pressure Pain Thresholds.

Pain Med 2018 11;19(11):2267-2273

University of Canberra Research Institute for Sport and Exercise (UCRISE), Australia.

Objective: Pain pressure thresholds (PPT) are used to study peripheral and central pain processing. In the tendon, pathological changes may exist without pain. This pilot study aimed to compare PPT between individuals with normal tendons and asymptomatic tendon pathology, and between individuals with and without a history of tendon pain.

Methods: The patellar, Achilles, and supraspinatus tendons of 128 asymptomatic participants were examined with ultrasound. Global PPT average was determined using a digital algometer at the patellar tendon, quadriceps muscle, L3 spinous process, and deltoid muscle insertion. Participants were separated into three groups: (1) healthy control group (no pathology, no history of pain), (2) tendon pathology at any site without a history of pain, (3) history of tendon pain anywhere.

Results: There were 92 controls, seven with asymptomatic pathology and 29 with a history of tendon pain. Asymptomatic tendon pathology at any site (without a history of pain) was associated with globally increased PPTs compared with controls (P < 0.001, pathology N = 7, N = 92 controls). Matched pair analysis remained significant (P < 0.004). A history of tendon pain was associated with globally increased PPTs compared with the control group (P = 0.026). Matched pair analysis was not significant (P = 0.122).

Conclusions: Asymptomatic tendon pathology is associated with higher PPTs. These findings point toward central nervous system adaptations but in a novel way-central desensitization. This challenges the validity of conclusions drawn from PPT studies that do not verify normal structure in the control group; artificial inflation of control group data may incorrectly indicate decreased PPTs in the comparison group.
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November 2018

Pain mapping of the anterior knee: injured athletes know best.

Scand J Pain 2018 07;18(3):409-416

La Trobe Sport and Exercise Medicine Centre (LASEM), La Trobe University, Bundoora VIC, Australia.

Background and aims Research investigating differences in pain location and distribution across conditions is lacking. Mapping a patient's pain may be a useful way of understanding differences in presentations, however the use of pain mapping during a pain provocation task has not been investigated. The aim of this study was to assess the reliability of patient and clinician rated pain maps during a pain provocation task for the anterior knee. Methods Participants were recruited from a larger study of professional Australian rules football players (n=17). Players were invited to participate if they reported a current or past history of patellar tendon pain. No clinical diagnosis was performed for this reliability study. Participants were asked to point on their own knee where they usually experienced pain, which was recorded by a clinician on a piloted photograph of the knee using an iPad. Participants then completed a single leg decline squat (SLDS), after which participants indicated where they experienced pain during the task with their finger, which was recorded by a clinician. Participants then recorded their own self-rated pain map. This process was repeated 10 min later. Pain maps were subjectively classified into categories of pain location and spread by two raters. Pain area was quantified by the number of pixels shaded. Intra- and inter-rater reliability (between participants and clinicians) were analysed for pain area, similarity of location as well as subjective classification. Results Test-retest reliability was good for participants (intraclass correlation coefficients [ICC]=0.81) but only fair for clinicians (ICC=0.47) for pain area. There was poor agreement between participants and clinicians for pain area (ICC=0.16) and similarity of location (Jaccard index=0.19). Clinicians had good inter- and intra-rater reliability of classification of pain spread (k=0.75 and 0.67). Conclusions Participant completed pain maps were more reliable than clinician pain maps. Clinicians were reliable at classifying pain based on location and type of spread. Implications Clinicians should ask patients to complete their own pain maps following a pain provocation test, to elicit the most reliable and consistent understanding of their pain perception.
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July 2018