Soft-Tissue Mobilization and Pain Neuroscience Education for Chronic Nonspecific Low Back Pain with Central Sensitization: A Prospective Randomized Single-Blind Controlled Trial

Effect of pain neuroscience education+ (PNE+) in people with different mechanisms of chronic pain: A systematic review and meta-analysis

BACKGROUND

Chronic pain poses a multifaceted and prevalent challenge that significantly affects an individual's quality of life. Sensory mechanisms, behavioural components (kinesiophobia and catastrophising), and social factors can influence pain perception in both younger and older populations. Moreover, the mechanisms underlying these altered pain phenotypes require further investigation in order to plan appropriate treatment. While Pain Neuroscience Education (PNE) has proven effective in managing chronic pain and previous research has been conducted on PNE physiotherapeutic techniques, there remains insufficient evidence on the efficacy of these adjunctive treatments.

OBJECTIVE

The objective of the present systematic review and meta-analysis was to evaluate the evidence for the efficacy of PNE + PT (PNE+) on pain as a primary outcome and 12 other psychosocial variables as secondary outcomes in patients with different pain mechanisms, and whether PNE+ could be applied to painful diabetic neuropathy.

METHODS

A thorough literature search was conducted in the database Scopus, MEDLINE/PubMed, ScienceDirect, CINAHL, and Web of Science, using keywords like "Pain Neuroscience Education", and "Chronic Pain" from 2010 to 2024 based on inclusion and exclusion criteria. Twenty of the 2558 studies that underwent screening qualified for a meta-analysis and 24 of them for a systematic review. Cochrane Risk of Bias 2 was used to assess the quality of the studies. Forest plots were generated using the Revman 5.3 software.

RESULTS

Studies that predominantly addressed central sensitization and neuropathic pain demonstrated moderate-to good-quality evidence. The review findings indicate that PNE+ is effective in reducing experienced pain intensity and experienced pain interference on the Visual Analogue Scale (VAS: SMD -0.70, 95% CI -1.26 to -0.14), Numerical Pain Rating Scale (NPRS SMD -1.71, 95% CI -2.34 to -1.08), reduced kinesiophobia (Tampa scale of Kinesiophobia: SMD -5.29, 95% CI -7.33 to -3.25), and catastrophizing (pain catastrophizing scale: -3.82, 95% CI -6.44 to -1.21).

CONCLUSION

PNE + has been found to be an effective intervention for reducing perceived pain experience, pain interference and other psychosocial variables in the management of chronic pain with different pain mechanisms. Most studies have focused on central sensitization, urging future research to explore PNE+ efficacy in neuropathic pain, such as painful diabetic neuropathy.

PROSPERO REGISTRATION NUMBER

CRD42023451101.

Is chronic pain caused by central sensitization? A review and critical point of view

Chronic pain causes disability and loss of health worldwide. Yet, a mechanistic explanation for it is still missing. Frequently, neural phenomena, and among them, Central Sensitization (CS), is presented as causing chronic pain. This narrative review explores the evidence substantiating the relationship between CS and chronic pain: four expert researchers were divided in two independent teams that reviewed the available evidence. Three criteria were established for a study to demonstrate a causal relationship: (1) confirm presence of CS, (2) study chronic pain, and (3) test sufficiency or necessity of CS over chronic pain symptoms. No study met those criteria, failing to demonstrate that CS can cause chronic pain. Also, no evidence reporting the occurrence of CS in humans was found. Worryingly, pain assessments are often confounded with CS measures in the literature, omitting that the latter is a neurophysiological and not a perceptual phenomenon. Future research should avoid this misconception to directly interrogate what is the causal contribution of CS to chronic pain to better comprehend this problematic condition.

Pain neuroscience education for patients with chronic pain: A scoping review from teaching-learning strategies, educational level, and cultural perspective

OBJECTIVE

(1) To identify the characteristics of PNE programs in terms of teaching-learning strategies, session modality, content delivery format, number of sessions, total minutes and instructional support material used in patients with chronic musculoskeletal pain, (2) to describe PNE adaptations for patients with different educational levels or cultural backgrounds, and (3) to describe the influence of the patient's educational level or cultural background on the effects of PNE.

METHODS

The PRISMA guideline for scoping reviews was followed. Nine databases were systematically searched up to July 8, 2023. Articles that examined clinical or psychosocial variables in adults with chronic musculoskeletal pain who received PNE were included.

RESULTS

Seventy-one articles were included. Studies found benefits of PNE through passive/active teaching-learning strategies with group/individual sessions. However, PNE programs presented great heterogeneity and adaptations to PNE were poorly reported. Most studies did not consider educational level and culture in the effects of PNE.

CONCLUSIONS

Despite the large number of studies on PNE and increased interest in this intervention, the educational level and culture are poorly reported in the studies.

PRACTICAL IMPLICATIONS

It is recommended to use passive and/or active teaching-learning strategies provided in individual and/or group formats considering the patient's educational level and culture.

Effects of Manual Therapy Plus Pain Neuroscience Education with Integrated Motivational Interviewing in Individuals with Chronic Non-Specific Low Back Pain: A Randomized Clinical Trial Study

Background and Objectives: Chronic non-specific low back pain (CNLBP) persists beyond 12 weeks. Manual therapy recommended for CNLBP demonstrates short-term efficacy. Pain Neuroscience Education (PNE) teaches patients to modify pain perception through explanations, metaphors, and examples, targeting brain re-education. Motivational Interviewing (MI) enhances motivation for behavioral change, steering patients away from ambivalence and uncertainty. These approaches collectively address the multifaceted nature of CNLBP for effective management. The aim of this study was to investigate a manual therapy intervention combined with PNE with MI on pain, pressure pain threshold (PPT), disability, kinesiophobia, catastrophizing, and low back functional ability in individuals experiencing CNLBP. Materials and Methods: Sixty adults with CNLBP were randomly divided into three equal groups (each n = 20). The first group received manual therapy and PNE with integrated MI (combined therapy group), the second group underwent only manual therapy (manual therapy group), and the third group followed a general exercise program at home (control group). Pain in the last 24 h was assessed using the Numeric Pain Rating Scale (NPRS), functional ability with the Roland-Morris Disability Questionnaire (RMDQ), PPT in the lumbar region through pressure algometry, kinesiophobia with the Tampa Scale for Kinesiophobia (TSK), catastrophizing with the Pain Catastrophizing Scale (PCS), and performance using the Back Performance Scale (BPS) at baseline, in the fourth week, and six months post-intervention. Results: Statistically significant differences between the intervention groups and the control group were found in both the fourth-week measurement and the six-month follow-up, as evident in the NPRS and RMDQ scores, as well as in the total values of tested PPTs (p < 0.05). Differences were also observed between the two intervention groups, with a statistically greater improvement in the combined therapy group at both time points (fourth week and six-month follow-up) (p < 0.05). Regarding the TSK and PCS scores in the fourth week, statistically significant differences were observed between the two intervention groups compared to the control group, as well as between the two intervention groups (p < 0.05). However, in the six-month follow-up, statistically significant differences were found only between the combined therapy group and the other two groups, with the combined therapy group showing significant improvements (p < 0.05). In relation to BPS, both intervention groups exhibited statistically significant differences compared to the control group in the fourth week, without any significant differences between the two intervention groups. However, in the six-month follow-up, significant differences were noted between the combined therapy group and the other two groups (p < 0.05), with combined therapy demonstrating greater improvement. Conclusions: The addition of PNE with integrated MI enhanced the positive effects of a manual therapy intervention in all outcome measures. The combination of manual therapy plus PNE with integrated MI appeared to provide greater improvements compared to the isolated application of manual therapy, and these improvements also lasted longer. These short- and long-term positive effects are likely attributed to the combination of PNE with integrated MI, which contributed to increasing the effectiveness of the treatment. Further studies are required to investigate the optimum dosage of manual therapy and PNE with integrated MI in individuals with CNLBP.