Pain Neuroscience Education and Physical Therapeutic Exercise for Patients with Chronic Spinal Pain in Spanish Physiotherapy Primary Care: A Pragmatic Randomized Controlled Trial

A cross-sectional study on pain neurophysiology knowledge among Spanish primary healthcare professionals

Healthcare professionals' (HCPs) knowledge and beliefs about pain are known to influence the treatment outcomes. The objective of this descriptive cross-sectional study was to evaluate the knowledge of the neurophysiology of pain among HCPs working with pain patients in primary care. Physiotherapists, nurses, physicians, nursing assistants, social workers and dentists of primary care were surveyed using the Neurophysiology of Pain Questionnaire (NPQ)(range 0-19) between September-December of 2022. Data on demographics, job-related information, own chronic musculoskeletal pain experience and specific training in the management/treatment of chronic musculoskeletal pain were collected and analyzed. Out of 1265 HCPs contacted, 510 (40.3%) participated and completed the survey. They were mostly women (78%), with a mean age of 49.5 ± 11.9 years. The NPQ score was 12.8 ± 2. Physiotherapists scored highest (14.4 ± 2). HCPs with chronic musculoskeletal pain scored less than those without, 12.5 ± 2 vs. 13 ± 1.8 (p < 0.01). The most reported areas of pain were the lumbar spine (25.3%) and neck (24.5%). No differences were found between sexes, age or healthcare profession. Primary HCPs demonstrated low to moderate levels of knowledge in pain neurophysiology, with room for improvement, particularly among those experiencing chronic musculoskeletal pain themselves. These findings suggest a need for enhanced pain management training, both within university curricula and through ongoing professional development programs for HCPs.

[Multidisciplinary group intervention for the management of non-cancer chronic pain in adults]

Chronic non-oncological pain (CNOP) is a common cause of primary care consultation. It affects physical and mental health, and is frequently associated with disability. The usual treatments are pharmacological, while education and exercise strategies recommended by clinical guidelines are rarely used.

OBJECTIVE

To evaluate a group intervention based on education, psychological intervention and physical exercise to manage CNOP and/or fibromyalgia.

MATERIALS AND METHODS

Pilot study, without control group, conducted in Primary Care. We evaluated three groups, with a total of 42 adults with CNOP and/or fibromyalgia.

INTERVENTION

neuroscience education (1 session), psycho-educative groups (5 sessions) and physical exercise (5 sessions). We measured the change in perceived pain with the visual analogue scale (VAS), quality of life with the SF-36 version 2 questionnaire and number of chronic analgesics used, and we analyzed the data with the paired sample Student's t test (statistical significance: p<0.05).

RESULTS

Perceived pain decreased on average by 0.59 (SD: 1.59) (p=0.057), the number of analgesics used by 0.32 (SD: 0.72) (p=0.008) and the SF-36 score increased 3.83 (SD: 8.89) (p=0.031). The dimensions of the SF-36 questionnaire that improved were bodily pain, with a mean variation of 7.25 (SD: 13.90) (p=0.01), social function 7.58 (SD: 16.43) (p=0.021), mental health 9.46 (16.57) (p=0.005) and vitality 7.59 (SD: 18.66) (p=0.041).

CONCLUSIONS

A group intervention with active strategies based on neurosciences education, psychological intervention, and physical exercise was useful to reduce pain and chronical use of analgesics and improve the quality of life of patients with CNOP.

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.

Pain revolution in the public health system: Active coping strategies for chronic pain unit

BACKGROUND

Chronic pain represents a global health challenge demanding a transition from traditional biomedical to patient-centered biopsychosocial models. This masterclass explores active coping strategies for effective chronic pain management within healthcare systems. It describes the Unit of Active Coping Strategies for Chronic Pain (UAAD - Unidad de Afrontamiento Activo para el Dolor) in Primary Care in Valladolid, Spain, as a successful example of implementing a biopsychosocial care model for treating chronic pain.

OBJECTIVE

To provide tools that allow the application of active coping strategies in the treatment of patients with chronic pain and how to implement the UAAD units in other healthcare systems.

METHODS

This masterclass describes the UAAD's innovative approach, starting with its comprehensive and personalized methodology. This includes a referral system, a thorough assessment encompassing biological, psychological, and social factors, and a functional categorization system. These elements guide personalized treatment plans delivered through group and individual programs grounded in therapeutic exercise and pain science education. Four key pillars are highlighted: clinical care, teaching, resource management, research and dissemination.

CONCLUSION

Embracing this model empowers healthcare providers to address the growing burden of chronic pain. It also enables patients to take an active role in their recovery and self-management.

[Low back pain: Our greatest enemy? Brief advice on pain in primary care]

This article rewievs the available evidence on low back pain, one of the most prevalent conditions and the main cause of disability in most countries according to the latest Global Disease Burden 2021 study, which has led entities such as the WHO to recently publish recommendations on low back pain management. The causes and associated risk factors are analyzed, with more than 90% of low back pain cases being nonspecific and closely related to biopsychosocial context, as well as the role of imaging tests, whose findings have not been proven to be the source of low back pain. Finally, the effectiveness of the different treatments is analyzed, with non pharmacological being the first-line of treatment and pharmacological treatment having a very limited role, despite the excessive use we make of it.

Pain Neuroscience Education Reduces Pain and Improves Psychological Variables but Does Not Induce Plastic Changes Measured by Brain-Derived Neurotrophic Factor (BDNF): A Randomized Double-Blind Clinical Trial

INTRODUCTION

PNE, focusing on cognitive aspects, aims to change patients' beliefs about pain. However, it is unclear if these cognitive changes are sufficient to influence other components such as neuroplastic changes.

OBJECTIVE

To assess whether 3-h pain neuroscience education (PNE) can induce changes in brain-derived neurotrophic factor (BDNF) levels and pain intensity in chronic pain patients.

METHODS

A double-blind randomized clinical trial was conducted with 66 participants aged 18-65 years old (50.86 ± 8.61) with chronic primary musculoskeletal pain divided into two groups: an intervention group receiving 3-h PNE lecture and a control group that received an educational booklet. Primary outcomes included plasma BDNF levels and perceived pain intensity (VAS). Secondary outcomes included anxiety (HADS-A), depression (HADS-D), catastrophizing (PCS), kinesiophobia (TSK), stress (PSS), and knowledge about pain. Measurements were taken in both groups before and after a three-hour intervention. Data were analyzed using paired t-tests and Cohen's d for effect sizes.

RESULTS

The results showed no significant changes in BDNF levels for the PNE lecture group (p = 0.708) or the educational booklet group (p = 0.298). Both groups showed significant reductions in pain intensity (PNE: p < 0.001, d = 0.70; booklet: p = 0.036, d = 0.39). Secondary variables, such as knowledge (PNE: p < 0.001, d = -0.972; booklet: p < 0.001, d = -0.975) and anxiety (PNE: p < 0.001, d = 0.70; booklet: p = 0.035, d = 0.39), also showed significant improvements.

CONCLUSIONS

PNE did not significantly change BDNF levels but effectively improved pain intensity, pain-related knowledge, and other clinical variables. These findings suggest that while PNE has cognitive benefits, it may not be sufficient to induce immediate neurobiological changes. Further research is needed to explore long-term effects and incorporate additional therapeutic domains.

Effectiveness of Adding a Pain Neuroscience Education Program to a Multimodal Physiotherapy Intervention in Patients with Chronic Shoulder Pain: A Randomized Clinical Trial

Objectives: The purpose of this study was to assess the efficacy of a pain neuroscience education program completed by patients with shoulder pain. Methods: A randomized, controlled trial was performed. Fifty-five patients satisfied the eligibility criteria, agreed to participate, and were randomized into an experimental group (n = 27) or control group (n = 28). A manual therapy and exercises program was administered for both groups. The experimental group also received a 4-week pain neuroscience education protocol (1 session/week, 75 min per session). The measurements taken included the active range of motion, pain, disability, catastrophizing, kinesiophobia, and therapeutic alliance. The outcomes were assessed at baseline and 5 weeks after completion of treatment. The primary outcome analyzed was the group × time interaction. Results: The 2 × 2 analysis of variance revealed a significant group × time interaction for the active range of motion (F = 15.27; p = 0.011), disability (F = 6.14; p = 0.01), catastrophizing (F = 8.79; p = 0.01), kinesiophobia (F = 7.62; p = 0.008), and therapeutic alliance (p = 0.03) in favor of the experimental group. Conclusions: This study showed that the patients with shoulder pain who completed the pain neuroscience program achieved significantly better results in terms of their active range of motion, disability, catastrophizing, kinesiophobia, and therapeutic alliance compared to those achieved by the control group. Therefore, pain neuroscience education may be beneficial in the treatment of patients with shoulder pain.

Multimodal intervention based on physical exercise, mindfulness, behaviour change and education to improve pain and health in patients with chronic primary low back pain: a study protocol of the HEALTHYBACK randomised controlled trial

The HEALTHYBACK trial is based on a multimodal intervention to determine the effectiveness of a supervised physical exercise, mindfulness, behaviour change and pain neuroscience education programme on several health variables in individuals with chronic primary low back pain (CPLBP). The study will be a randomised controlled trial among 70 individuals diagnosed with CPLBP (aged 18-65 years). The intervention will be conducted in person within a hospital setting for 16 weeks and comprises a first phase (16 sessions supervised physical exercise (2 days/week, 45 min/session), mindfulness (1 day/week, 2.5 hours/session), behaviour change (daily/24 hours via a wrist-worn activity prompting device) and pain neuroscience education (1 day/biweekly, 2 hours/session)) and a second phase (16 sessions functional full-body muscle strengthening exercise, 3 days/week, 50 min/session). The primary outcomes will include perceived acute pain, pain pressure threshold, conditioned pain modulation, temporal summation of pain and disability due to pain. Secondary measures will include physical fitness, body composition, gait parameters, device-measured physical activity and sedentary behaviour, haematological profile, self-reported sedentary behaviour, quality of life, pain catastrophising, mental health, sleep duration and quality, and symptoms related to central sensitisation. The groups will undergo pretest (before the intervention), post-test (after each phase of the intervention) and retest (at a 6-week detraining period after the intervention) measurements. The results will determine the effectiveness of multidimensional interventions on several health parameters in individuals with CPLBP. They will provide knowledge for pain management and functioning in affected individuals, which might diminish the need for primary healthcare services. Trial registration number: NCT06114264.

Short- and medium-term effects of a single session of pain neuroscience education on pain and psychological factors in patients with chronic low back pain. A single-blind randomized clinical trial

INTRODUCTION

Biopsychosocial approach in patients suffering chronic low back pain (CLBP) promotes pain self-management strategies. Current evidence recommends high dose of Pain Neuroscience Education (PNE) for clinically significant differences. However, the workload and time constraints experienced by healthcare providers impede the application of the recommended treatment regimen. In fact, Back School with a biomechanical model is the main approach to manage CLBP in public systems.

OBJECTIVE

The objective of this study is to explore the effect of a 60 min single session of PNE as an adjunct to back school on pain intensity and psychological variables patients with CLBP.

METHODS

A double-blind, two-arm randomized controlled clinical trial was conducted in patients with CLBP who attended back school sessions held in a Spanish public hospital. A total of 121 patients were randomized into control group, who received the Back School program during 5 weeks, and intervention group, who additionally received a single session of PNE. Patient-reported outcomes were the Numerical Pain Rating Scale, Central Sensitization Inventory, Pain Catastrophizing Scale, and Tampa Scale of Kinesiophobia, with a 12-week follow-up.

RESULTS

A total of 113 patients were analysed. Intervention and control group presented similar effects on pain and kinesiophobia. At follow-up, intervention group exhibited reduced sensitization and catastrophism scores compared with control, including the subscales. Additionally, PNE reduced the percentage of participants classified as having central sensitization compared with control.

CONCLUSIONS

Adding a single PNE session in the back school program did not reduce pain but improved psychological factors as central sensitization and pain catastrophizing at medium-term. This study highlights the potential of PNE to optimize treatment strategies for CLBP, especially in public health centres where time resources are scarce.

SIGNIFICANCE STATEMENT

Adding a single PNE session in the back school program did not reduce pain but improved psychological factors as central sensitization and pain catastrophism at medium-term.

An Evaluation of the Design of Multimedia Patient Education Materials in Musculoskeletal Health Care: Systematic Review

BACKGROUND

Educational multimedia is a cost-effective and straightforward way to administer large-scale information interventions to patient populations in musculoskeletal health care. While an abundance of health research informs the content of these interventions, less guidance exists about optimizing their design.

OBJECTIVE

This study aims to identify randomized controlled trials of patient populations with musculoskeletal conditions that used multimedia-based patient educational materials (PEMs) and examine how design was reported and impacted patients' knowledge and rehabilitation outcomes. Design was evaluated using principles from the cognitive theory of multimedia learning (CTML).

METHODS

PubMed, CINAHL, PsycINFO, and Embase were searched from inception to September 2023 for studies examining adult patients with musculoskeletal conditions receiving multimedia PEMs compared to any other interventions. The primary outcome was knowledge retention measured via test scores. Secondary outcomes were any patient-reported measures. Retrievability was noted, and PEMs were sourced through search, purchase, and author communication.

RESULTS

A total of 160 randomized controlled trials were eligible for inclusion: 13 (8.1%) included their educational materials and 31 (19.4%) required a web search, purchase, or direct requests for educational materials. Of these 44 (27.5%) studies, none fully optimized the design of their educational materials, particularly lacking in the CTML principles of coherence, redundancy, modality, and generative activities for the learner. Of the 160 studies, the remaining 116 (72.5%) contained interventions that could not be retrieved or appraised. Learning was evaluated in 5 (3.1%) studies.

CONCLUSIONS

Musculoskeletal studies should use open science principles and provide their PEMs wherever possible. The link between providing multimedia PEMs and patient learning is largely unexamined, but engagement potential may be maximized when considering design principles such as the CTML.

The effectiveness of cognitive functional therapy on patients with chronic neck pain: A systematic literature review

OBJECTIVE

Recently, psychological, and behavioral interventions such as cognitive functional therapy (CFT) has gained significant attention in musculoskeletal rehabilitation. We aimed to compare interventions with a CFT component in adults (>18 years old) suffering from chronic neck pain (CNP) or chronic whiplash associated disorders (>3 months) with another intervention or no intervention, in pain, disability, kinesiophobia, or any other reported outcome measure.

RESULTS

One case-study and three randomized controlled trials met the eligibility criteria. Statistically and clinically significant improvement in pain was found in favour of CFT combined with scapular exercise compared to exercise alone (MD = -19.91; 95%CI: -24.18 to -15.64) and controls (MD = -48.91; 95%CI: -53.88 to -43.94) at the very-short term follow-up. A significant difference in kinesiophobia was found at the short-term follow-up in favour of CFT and exercise compared to exercise alone (MD = -13.23; 95%CI-16.94 to -9.52) and controls (MD = -40.81 95%CI: -44.55 to -37.07). Finally, statistically and clinically significant improvement was found in favour of CFT compared to controls at the short-term follow-up in stress (MD = -36.62, 95%CI: 43.47 to -29.77), fear avoidance (MD = -35.44; 95%CI: 42.57 to -28.31), anxiety (MD = -34.43; 95%CI: 41.90 to -26.96), pain catastrophizing (MD = -25.19; 95%CI: 32.49 to -17.89), depression (MD = -30.72; 95%CI: 38.37 to -23.07), but a significant and clinically difference in favour of the control group at self-efficacy (MD = 29.56; 95%CI20.70 to 38.42).

CONCLUSIONS

Very low certainty evidence suggests that CFT alone or in combination with exercise may produce better outcomes than no treatment or exercise alone. The results should be interpreted with caution, given that the number of studies assessing CFT in CNP is limited.

Manual therapists' appraisal of optimal non-pharmacological conservative management of patients with lumbar spinal stenosis. An international Delphi study

BACKGROUND

Lumbar Spinal Stenosis (LSS) is a slow progressive degenerative disorder associated with chronic pain and disability. Although consensus-based international guidelines for invasive treatment of patients with LSS exist, few consensus-based guidelines for optimal conservative management strategies have been published.

OBJECTIVE

To achieve manual therapists' consensus on optimal physiotherapeutic management strategies for LSS.

METHODS

The study employed a three-round, email-based International Delphi survey. All qualified members of the International Maitland Teacher Association (IMTA) (n = 30) were invited to participate.

RESULTS

Twelve IMTA teachers participated in the study. Eight essential physiotherapy management strategies were identified, as follows: 1. Detailed assessment with in-depth interview; 2. Recognition of red flags, contraindications and precautions; 3. Neurological examination; 4. Postural and movement analysis with related ergonomics; 5. Functional analysis; 6. Individualized treatment based on assessment findings and research evidence; 7. Aerobic training and 8. Patient education.

CONCLUSION

This Delphi survey provides a foundation for physiotherapists to individualize and optimise management approaches for patients with LSS. With a growing elderly population, there is an increasing need for evidence-based conservative management guidelines based on high quality research.

Efficacy of preoperative pain neuroscience education in physical therapy on clinical outcomes in patients undergoing arthroplasty: A systematic review of randomized clinical trials

OBJECTIVE

To evaluate the efficacy of preoperative pain neuroscience education (PNE) on pain intensity, kinesiophobia, catastrophizing, and disability in individuals undergoing hip or knee arthroplasty.

METHODS

A search was conducted on MEDLINE, CINAHL, Epistemonikos, Scopus, and Web of Science from their inception to March 2023. Two investigators independently assessed the risk of bias with Risk of Bias 2 (ROB2) and Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) of the studies, as well as the certainty of the evidence with Grade of Recommendation, Assessment, Development, and Evaluation (GRADE) for pain intensity, catastrophizing, kinesiophobia and disability at one month, three months and six months of follow-up.

RESULTS

A total of 1716 papers were found and two studies on knee arthroplasty were included (n = 147). The intergroup effect sizes for pain intensity were 0.29, 0.07, and 0.25 at one-, three-, and six-months post-surgery, whereas the effect sizes for disability were 0.4, 0.46, and 0.21 (GRADE analysis, moderate certainty, respectively). Catastrophizing showed intergroup effect sizes of 0.78, 1.08, and 0.25, and kinesiophobia of 1.56, 0.92, and 0.33 at follow-up (GRADE analysis, low-moderate certainty).

CONCLUSIONS

Preoperative PNE in individuals undergoing knee arthroplasty has low to moderate certainty for improving pain intensity, catastrophizing, kinesiophobia, and disability with low to high effect sizes and discrepancy between studies. More research on the effect of a preoperative PNE intervention in people undergoing knee or hip arthroplasty is required.

Pain Education and Virtual Reality Improves Pain, Pain-related Fear of Movement, and Trunk Kinematics in Individuals With Persistent Low Back Pain

OBJECTIVES

To evaluate the effect of combining pain education and virtual reality (VR) exposure therapy using a cognitive-behavioral therapy-informed approach (virtual reality-based cognitive behavioral therapy [VR-CBT]) on pain intensity, fear of movement, and trunk movement in individuals with persistent low back pain.

MATERIALS AND METHODS

Thirty-seven participants were recruited in a single cohort repeated measures study, attending 3 sessions 1 week apart. The VR-CBT intervention included standardized pain education (session 1) and virtual reality-based exposure therapy (VRET; session 2) incorporating gameplay with mixed reality video capture and reflective feedback of performance. Outcome measures (pain intensity, pain-related fear of movement (Tampa Scale of Kinesiophobia), and trunk kinematics during functional movements (maximum amplitude and peak velocity) were collected at baseline (session 1) and 1 week after education (session 2) and VRET (session 3). One-way repeated measures analysis of variances evaluated change in outcomes from baseline to completion. Post hoc contrasts evaluated effect sizes for the education and VR components of VR-CBT.

RESULTS

Thirty-four participants completed all sessions. Significant ( P < 0.001) reductions were observed in mean (SD) pain (baseline 5.9 [1.5]; completion 4.3 [2.1]) and fear of movement (baseline 42.6 [6.4]; completion 34.3 [7.4]). Large effect sizes (Cohen d ) were observed for education (pain intensity: 0.85; fear of movement: 1.28), whereas the addition of VRET demonstrated very small insignificant effect sizes (pain intensity: 0.10; fear of movement: 0.18). Peak trunk velocity, but not amplitude, increased significantly ( P < 0.05) across trunk movement tasks.

CONCLUSION

A VR-CBT intervention improved pain, pain-related fear of movement, and trunk kinematics. Further research should explore increased VR-CBT dosage and mechanisms underlying improvement.

The Mediating Role of Pain Cognitions and Pain Sensitivity in the Treatment Effect of Perioperative Pain Neuroscience Education in People Undergoing Surgery for Lumbar Radiculopathy

Though perioperative pain neuroscience education (PPNE) positively influences patients' surgical outcomes, little is known about the mechanisms behind this treatment's success. Therefore, this study aims to evaluate the potential mediating role of pain cognitions and pain sensitivity in the treatment effect of PPNE on postoperative quality of life in people undergoing surgery for lumbar radiculopathy. This secondary analysis uses data from 120 participants of a randomized controlled trial who were randomized to receive either PPNE or perioperative biomedical education before undergoing surgery for lumbar radiculopathy. Quality of life was assessed 1-year postsurgery using the short form 36-item health survey (SF36) physical and mental component scores. Potential mediators included pain cognitions (ie, kinesiophobia, pain catastrophizing, and hypervigilance) and pain sensitivity (ie, endogenous nociceptive modulation), assessed 6 weeks postsurgery. Mediation models were constructed using structural equation modeling, and 95% confidence intervals (CIs) were calculated using 10,000 bootstrap samples. Analyses show a significant total effect for PPNE (estimate = .464, 95% CI [.105, .825]) and a significant indirect effect via pain catastrophizing on the SF36 physical component (estimate = .124, 95% CI [.001, .293]). No mediating effect was found through the remaining pain cognitions or pain sensitivity measures. Also, no potential mediators were identified for the treatment effect of PPNE on the SF36 mental component. Our findings suggest that pain catastrophizing mediates the treatment effect of PPNE on physical health-related quality of life in people undergoing surgery for lumbar radiculopathy. PERSPECTIVE: This secondary analysis identified pain catastrophizing as a mediator for PPNE in people undergoing surgery for lumbar radiculopathy. More so, its findings indicate that this educational intervention can enhance the postoperative physical health-related quality of life of these patients by addressing their catastrophizing thoughts. TRIAL REGISTRATION: Clinicaltrials.gov (NCT02630732).

The optimal dose of pain neuroscience education added to an exercise programme for patients with chronic spinal pain: a systematic review and dose-response meta-analysis

ABSTRACT

Pain neuroscience education (PNE) has shown promising results in the management of patients with chronic spinal pain (CSP). However, no previous review has determined the optimal dose of PNE added to an exercise programme to achieve clinically relevant improvements. The aim was to determine the dose-response association between PNE added to an exercise programme and improvements in pain intensity and disability in patients with CSP. A systematic search of PubMed/MEDLINE, Embase, Web of Science, Scopus, and the Cochrane Library was conducted from inception to April 19, 2023. The exposure variable (dosage) was the total minutes of PNE. Outcome measures included pain intensity, disability, quality of life, pressure pain thresholds, and central sensitization inventory. Data extraction, risk-of-bias assessment, and certainty of evidence were performed by 2 independent reviewers. The dose-response relationship was assessed using a restricted cubic spline model. Twenty-six randomised controlled trials with 1852 patients were included. Meta-analysis revealed a statistically significant effect in favour of PNE on pain intensity and disability. In addition, a dose of 200 and 150 minutes of PNE added to an exercise programme was estimated to exceed the minimum clinically important difference described in the literature for pain intensity (-2.61 points, 95% CI = -3.12 to -2.10) and disability (-6.84 points, 95% CI = -7.98 to -5.70), respectively. The pooled effect of the isolated exercise was small. These findings may be useful in optimising the most appropriate PNE dose to achieve clinically relevant improvements in patients with CSP.

Tackling Kinesiophobia in Chronic Shoulder Pain: A Case Report on the Combined Effect of Pain Education and Whole-Body Cryostimulation

BACKGROUND

Chronic shoulder pain may cause significant functional disability and reduced psychosocial well-being. Detailed Case Description: In this case, we propose the use of pain neuroscience education and whole-body cryostimulation (WBC) to treat a 64-year-old woman with severe functional limitations and chronic right shoulder pain. The aim was to overcome kinesiophobia and improve her motor function, autonomy, and quality of life. Functional and clinical assessments were conducted at admission, discharge, and at a one-month follow-up via phone call. The patient's global health, shoulder function, and quality of life showed improvement during hospitalisation and were maintained after one month.

DISCUSSION

Pain education is crucial in managing chronic shoulder pain, especially in addressing kinesiophobia and promoting positive patient outcomes. In this context, WBC was used as a supplementary treatment to traditional pain relief and exercise tolerance therapies. This can help individuals to participate more actively in their rehabilitation process, ultimately promoting functional recovery and an improved quality of life.

CONCLUSION

The combination of cryostimulation, tailored physical exercises, pain education, manual therapy, and psychological support created a synergistic effect that addressed both the physical and psychological aspects of pain and kinesiophobia.

Subgroup characteristics in care workers with low back pain: cluster analysis-based severity of central sensitivity syndromes and low back pain

PURPOSE

This multicentre, collaborative, cross-sectional study aimed to explore the characteristics of subgroups based on central sensitivity syndromes (CSSs) and low back pain (LBP) severity. Furthermore, we investigated the relationship between the classified subgroups and work status among the care workers.

PATIENTS AND METHODS

In 660 care workers, we assessed LBP intensity, pain duration, pain sites, CSS (using the central sensitization inventory-9), psychological factors (using the pain catastrophizing scale and pain self-efficacy questionnaire), and work status (interference, amount of assistance, frequency of assistance, and work environment). We used hierarchical clustering analysis to divide the participants into subgroups based on CSS and LBP severity. We further performed multiple comparison analyzes and adjusted the residuals (chi-square test) to reveal differences between clusters.

RESULTS

Care workers with LBP were divided into four subgroups (Cluster 1: no CSS and mild LBP, Cluster 2: mild CSS and severe LBP, Cluster 3: mild CSS and mild LBP, Cluster 4: severe CSS and moderate LBP). Cluster 4 tended to have a higher number of pain sites, severe pain catastrophizing, and poor pain self-efficacy. In addition, Cluster 4 showed a higher frequency of assistance and an inadequate working environment and equipment. By contrast, Cluster 2 tended to have low pain self-efficacy. In addition, Cluster 2 experienced the highest work-related interference compared with any of the subgroups.

CONCLUSION

Our findings suggested that the severe LBP and severe CSS subgroups had common and different characteristics concerning psychological factors and work status, including interference with work. Our results may help to improve the management of care workers with LBP.

Characterizing clinical progression in patients with musculoskeletal pain by pain severity and central sensitization-related symptoms

Central sensitization-related symptoms (CSS) are associated with the severity and progression of pain. The relationship between the severity of pain/CSS and clinical progresses remains unclear. This multicenter, collaborative, longitudinal study aimed to characterize the clinical outcomes of patients with musculoskeletal pain by classifying subgroups based on the severity of pain/CSS and examining changes in subgroups over time. We measured the pain intensity, CSS, catastrophic thinking, and body perception disturbance in 435 patients with musculoskeletal pain. Reevaluation of patients after one month included 166 patients for pain intensity outcome and 110 for both pain intensity and CSS outcome analysis. We classified the patients into four groups (mild pain/CSS, severe pain/mild CSS, severe pain/CSS, and mild pain/severe CSS groups) and performed multiple comparison analyses to reveal the differences between the CSS severity groups. Additionally, we performed the adjusted residual chi-square to identify the number of patients with pain improvement, group transition, changing pain, and CSS pattern groups at baseline. The most characteristic result was that the mild and severe CSS groups showed worsening pain. Moreover, many of the group transitions were to the same group, with a few transitioning to a group with mild pain/CSS. Our findings suggest that the severity and improvement of CSS influence pain prognosis.

The effectiveness of a combined exercise and psychological treatment programme on measures of nervous system sensitisation in adults with chronic musculoskeletal pain - a systematic review and meta-analysis

BACKGROUND

Quantitative sensory testing (QST) offers information regarding underlying mechanisms contributing to chronic pain (CP) in adults with musculoskeletal disorders. This review examined the use of QST measures in adults with CP following participation in a combined exercise and psychological intervention.

METHODS

The review was conducted in accordance with the PRISMA guidelines. Five databases were searched from inception to November 2022. All study designs which evaluated the effects of a combined exercise and psychological treatment on measures of nervous system sensitivity in adults with chronic musculoskeletal pain were included.

RESULTS

A total of 13 studies met the selection criteria, 10 of which were included in a meta-analysis. Local pressure pain thresholds were the most frequently used measure (n = 12 studies). Meta-analysis revealed statistically significantly improvements in favour of the combined exercise and psychological intervention group, compared to a control group, for local pressure pain threshold measures [SMD = 0.44, 95% CI 0.08-0.81, I2 = 84%], pain intensity scores [SMD=-0.89, 95% CI -1.66- -0.13, I2 = 94%] and the Central Sensitisation Inventory [SMD=-0.69, 95% CI -1.37- -0.02, I2 = 87%]. There were no significant differences found between groups for remote pressure pain thresholds, temporal summation or conditioned pain modulation.

CONCLUSIONS

The results suggest that a combined exercise and psychological intervention may lead to greater improvements in local pressure pain threshold, pain intensity and Central Sensitisation Inventory scores when compared to a control intervention in adults with CP, however these findings must be interpreted with caution as a large degree of heterogeneity was present in these results (I2: 84-94%). Further large, longitudinal studies are required using standardised QST measurement procedures and patient reported outcome measures to explore changes in nervous system sensitisation.

TRIAL REGISTRATION

This systematic review is registered with PROSPERO, ID Number CRD42022380464.

Therapeutic management of the painful nerve: a narrative review of common rehabilitation interventions

There are many ways that rehabilitation therapists, including occupational and physical therapists, treat nerve-related pain. Commonly used interventions include neurodynamic treatment, pain neuroscience education, desensitization, exercise, physical agent modalities, mirror box therapy, and Kinesio taping. Despite common practice and anecdotal support, it can be challenging to determine the appropriate intervention for each patient. In this article, each of these treatment approaches is discussed, including indicated pain phenotypes and diagnoses, timing, efficacy, mechanism, contraindications, and limitations.

Effectiveness of Self-Care Education for Chronic Neck Pain: A Systematic Review and Meta-Analysis

Self-care programs for chronic neck pain are relevant to everyday life and can lead to long- term improvement. More studies on their effectiveness, key components and appropriate duration are needed. The aim of this study was to determine the effectiveness of self-care programs for patients with chronic neck pain. A systematic review and meta-analysis of randomized controlled trials was conducted according to the PRISMA guidelines. After searching in PubMed, Web of Science, Scopus and ScienceDirect, eleven studies met the inclusion criteria. Self-care education interventions typically consisted of education (i.e., pain neuro-science education or general educational concepts) accompanied by exercise or manual therapy. The most frequent components were addressing physical and psychological symptoms and engaging in self-care strategies. The least frequent ones were monitoring and recording symptoms and discussing with providers of medical care. The duration of the interventions ranged from three sessions to six months. Finally, individual and supervised modalities were the most frequent. After pooling the data, a meta-analysis was carried out according to four variables (i.e., pain, disability, kinesiophobia and catastrophization) and showed significant results (p < 0.05) in favor of self-care interventions. This systematic review and meta-analysis suggests that self-education interventions improve pain, psychological pain-related variables and disability in patients with chronic neck pain. The most frequently used components were addressing physical and psychological symptoms and engaging in self-care strategies. Future trials should focus on including other components, such as discussing symptoms with providers of medical care or self-monitoring symptoms. Additional areas of focus include more homogeneous doses and comparator treatments, as well as studies with better evidence to reach more solid conclusions.

Reductions in kinesiophobia and distress after pain neuroscience education and exercise lead to favourable outcomes: a secondary mediation analysis of a randomized controlled trial in primary care

ABSTRACT

Pain neuroscience education combined with exercise (PNE + exercise) is an effective treatment for patients with chronic spinal pain. Yet, however, little is known about its underlying therapeutic mechanisms. Thus, this study aimed to provide the first insights by performing a novel mediation analysis approach in a published randomized controlled trial in primary care where PNE + exercise was compared with standard physiotherapy. Four mediators (catastrophizing, kinesiophobia, central sensitization-related distress, and pain intensity) measured at postintervention and 3 outcomes (disability, health-related quality of life, and pain medication intake) measured at 6-month follow-up were included into the analysis. The postintervention measure of each outcome was also introduced as a competing candidate mediator in each respective model. In addition, we repeated the analysis by including all pairwise mediator-mediator interactions to allow the effect of each mediator to differ based on the other mediators' values. Postintervention improvements in disability, medication intake, and health-related quality of life strongly mediated PNE + exercise effects on each of these outcomes at 6-month follow-up, respectively. Reductions in disability and medication intake were also mediated by reductions in kinesiophobia and central sensitization-related distress. Reductions in kinesiophobia also mediated gains in the quality of life. Changes in catastrophizing and pain intensity did not mediate improvements in any outcome. The mediation analyses with mediator-mediator interactions suggested a potential effect modification rather than causal independence among the mediators. The current results, therefore, support the PNE framework to some extent as well as highlight the need for implementing the recent approaches for mediation analysis to accommodate dependencies among the mediators.

Effects of exercise/physical activity on fear of movement in people with spine-related pain: a systematic review

Background

Kinesiophobia (i.e., fear of movement) can be an important contributor for ongoing pain and disability in people with spine-related pain. It remains unclear whether physical activity interventions/exercise influence kinesiophobia in this population. A systematic review was therefore conducted to synthesize the available evidence on whether physical activity interventions/exercise influence kinesiophobia in people with chronic non-specific spine-related pain.

Methods

The study protocol was registered prospectively with PROSPERO (CRD42021295755). The following databases were systematically searched from inception to 31 January 2022 and updated on 22 June 2023: PubMed, MEDLINE, Embase, CINAHL, Web of Science, PsycINFO, ZETOC, PROSPERO and Google Scholar. Inclusion criteria were randomized or non-randomized controlled studies investigating adults aged ≥18 years, reporting the effect of exercise or physical activity on kinesiophobia in individuals with chronic non-specific spine-related pain. Two reviewers independently extracted data and assessed the quality of the included studies. Bias was assessed using the Cochrane ROB2 tool and evidence certainty via Grading of Recommendations Assessment, Development and Evaluation (GRADE).

Results

Seventeen studies from seven countries involving a total of 1,354 individuals were selected for inclusion. The majority of studies (n = 13) involved participants with chronic low back pain (LBP), and Pilates was the most common form of exercise evaluated. Most of the studies reported a positive direction of effect in favor of exercise reducing kinesiophobia when compared to a control group. There was moderate to high risk of bias among the studies and the overall certainty of the evidence was very low.

Conclusion

This review supports the use of exercise for reducing kinesiophobia in people with chronic LBP albeit with very low certainty of evidence; Pilates (especially equipment-based) was shown to be effective as were strengthening training programmes. There was limited evidence available on the effects of exercise on kinesiophobia for people with chronic neck or thoracic pain and further research is required.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=295755.

Carryover Effects of Pain Neuroscience Education on Patients with Chronic Lower Back Pain: A Systematic Review and Meta-Analysis

Background and Objectives: Because most individuals with chronic back pain (CLBP) have no specific cause, it is usually described as central sensitization. Pain neuroscience education (PNE) in top-down pain control may be effective against carryover effects; however, this remains unclear. In this study, the carryover effect was qualitatively and quantitatively synthesized and analyzed. Materials and Methods: Randomized controlled trials (RCTs) on PNE in individuals with CLBP were conducted using international databases until January 2023. Using RevMan5.4 provided by Cochrane, qualitative and quantitative analyses were performed with a risk of bias and meta-analysis, respectively. Results: Nine RCTs involving 1038 individuals with CLBP were included in the analysis. Four main results were identified: First, PNE had a short-term carryover effect on pain intensity (SMD = -1.55, 95% confidence interval [CI] = -2.59 to -0.50); second, PNE had a short-term carryover effect on pain catastrophizing (SMD = -2.47, 95% CI = -3.44 to -1.50); third, PNE had short- and long-term carryover effects on kinesiophobia (SMD = -3.51, 95% CI = -4.83 to -2.19); fourth, the appropriate therapeutic intensity of PNE for the pain intensity of individuals (SMD = -0.83, 95% CI = -1.60 to -0.07). Conclusions: PNE has a short-term carryover effect on pain intensity and pain cognition in individuals with CLBP and a long-term carryover effect on kinesiophobia.

Is there any benefit of adding a central nervous system-focused intervention to a manual therapy and home stretching program for people with frozen shoulder? A randomized controlled trial

BACKGROUND

Frozen shoulder (FS) is a highly disabling pathology of poorly understood etiology, which is characterized by the presence of intense pain and progressive loss of range of motion. The aim of this study was to evaluate the effect of adding a central nervous system (CNS)-focused approach to a manual therapy and home stretching program in people with FS.

METHODS

A total of 34 patients with a diagnosis of primary FS were randomly allocated to receive a 12-week manual therapy and home stretching program or manual therapy and home stretching program plus a CNS-focused approach including graded motor imagery and sensory discrimination training. The Shoulder Pain and Disability Index score, self-perceived shoulder pain (visual analog scale score), shoulder range of motion, and the Patient-Specific Functional Scale score were measured at baseline, after a 2-week washout period just before starting treatment, after treatment, and at 3 months' follow-up.

RESULTS

No significant between-group differences in any outcome were found either after treatment or at 3 months' follow-up.

CONCLUSION

A CNS-focused approach provided no additional benefit to a manual therapy and home stretching program in terms of shoulder pain and function in people with FS.

Additional effects of pain neuroscience education combined with physiotherapy on the headache frequency of adult patients with migraine: A randomized controlled trial

Aim To assess the efficacy of pain neuroscience education combined with physiotherapy for the management of migraine.Background Physiotherapy can significantly reduce the frequency of migraine, but the evidence is based only on a few studies. Pain neuroscience education might pose a promising treatment, as it addresses migraine as a chronic pain disease.Methods In this non-blinded randomized controlled trial, migraine patients received physiotherapy + pain neuroscience education or physiotherapy alone, preceded by a three-month waiting period. Primary outcomes were frequency of headache (with and without migraine features), frequency of migraine and associated disability.Results Eighty-two participants were randomized and analyzed. Both groups showed a decrease of headache frequency (p = 0.02, d = 0.46) at post-treatment (physiotherapy: 0.77 days, 95%CI: -0.75 to 2.29 and physiotherapy + pain neuroscience education: 1.25 days, 95%CI: -0.05 to 2.55) and at follow-up (physiotherapy: 1.93, 95%CI: 0.07 to 3.78 and physiotherapy + pain neuroscience education: 3.48 days, 95%CI: 1.89 to 5.06), with no difference between groups (p = 0.26, d = 0.26). Migraine frequency was reduced significantly in the physiotherapy + pain neuroscience education group, and not in the physiotherapy group, at post-treatment (1.28 days, 95%CI: 0.34 to 2.22, p = 0.004) and follow-up (3.05 days, 95%CI: 1.98 to 5.06, p < 0.0001), with a difference between groups at follow-up (2.06 days, p = 0.003). Migraine-related disability decreased significantly in both groups (physiotherapy: 19.8, physiotherapy + pain neuroscience education: 24.0 points, p < 0.001, d = 1.15) at follow-up, with no difference between groups (p = 0.583). Secondary outcomes demonstrated a significant effect of time with no interaction between time and group. No harm or adverse events were observed during the study.Conclusion In comparison to physiotherapy alone, pain neuroscience education combined with physiotherapy can further reduce the frequency of migraine, but had no additional effect on general headache frequency or migraine-related disability.Trial Registration The study was pre-registered at the German Clinical Trials Register (DRKS00020804).

Clarification of the "pain neuroscience education" concept in the management of patients with persistent low back pain: A scoping review

BACKGROUND

Patient education is a recommended treatment strategy for persistent low back pain (PLBP). Pain neuroscience education (PNE) is an emerging concept with boundaries still unclear.

OBJECTIVE

To clarify the PNE concept and identify its key characteristics in PLBP management.

METHODS

A systematic search was conducted using the following databases: Pubmed, ScienceDirect, Google Scholar, Cochrane, and Pedro.

INCLUSION CRITERIA

publications in English or French on pain neuroscience education and chronic low back pain, educational books cited in white literature. Three reviewers independently selected eligible studies for final inclusion. Numerical analysis and narrative synthesis were carried out from the extracted data.

RESULTS

From 919 identified publications, 54 were selected. Ten educational resources were added. PNE refers to a theoretical framework, a specific educational intervention, and an overall care approach. It is characterized by the intention to help the patient reconceptualize their PLBP from a tissue injury marker to a protective, neurobiological perspective, and then to increase adherence to biopsychosocial rehabilitation and normalize cognitive-behavioral responses. Pain sciences concepts are presented with an optimization of learning strategies.

CONCLUSION

PNE stands out from other educational and cognitive behavioral approaches through its objective of changing the pain concept.

The effects of pain science education plus exercise on pain and function in chronic Achilles tendinopathy: a blinded, placebo-controlled, explanatory, randomized trial

ABSTRACT

Exercise is the standard of care for Achilles tendinopathy (AT), but 20% to 50% of patients continue to have pain following rehabilitation. The addition of pain science education (PSE) to an exercise program may enhance clinical outcomes, yet this has not been examined in patients with AT. Furthermore, little is known about how rehabilitation for AT alters the fear of movement and central nervous system nociceptive processing. Participants with chronic AT (N = 66) were randomized to receive education about AT either from a biopsychosocial (PSE) or from a biomedical (pathoanatomical education [PAE]) perspective. Simultaneously, all participants completed an exercise program over 8 weeks. Linear mixed models indicated that there were no differences between groups in (1) movement-evoked pain with both groups achieving a clinically meaningful reduction (mean change [95% CI], PSE: -3.0 [-3.8 to -2.2], PAE = -3.6 [-4.4 to -2.8]) and (2) self-reported function, with neither group achieving a clinically meaningful improvement (Patient-Reported Outcomes Measurement Information System Physical Function-PSE: 1.8 [0.3-3.4], PAE: 2.5 [0.8-4.2]). After rehabilitation, performance-based function improved (number of heel raises: 5.2 [1.6-8.8]), central nervous system nociceptive processing remained the same (conditioned pain modulation: -11.4% [0.2 to -17.3]), and fear of movement decreased (Tampa Scale of Kinesiophobia, TSK-17: -6.5 [-4.4 to -8.6]). Linear regression models indicated that baseline levels of pain and function along with improvements in self-efficacy and knowledge gain were associated with a greater improvement in pain and function, respectively. Thus, acquiring skills for symptom self-management and the process of learning may be more important than the specific educational approach for short-term clinical outcomes in patients with AT.

Effect of aerobic exercises and therapeutic pain neuroscience education on disability, pain, head posture and QOL in migraine patients

Migraine is a type of primary headache with a high degree of associated disability that can present with a variety of indications and co-morbidities. The role of physical therapy treatment in migraine management is largely obscure. To investigate the combine effect of aerobic exercises and therapeutic pain neuroscience education on disability, pain pressure threshold, head posture and quality of life (QoL) in patients having migraine. Subjects were screened by using Migraine Disability Assessment (MIDAS) and after screening total sample of 50 subjects were randomly assigned into two groups: Group A (Experimental, n=25) and Group B (Control, n=25). Migraine disability assessment, pressure algometer, craniovertebral angle (CVA) and migraine specific quality of life were examined before and after 6 weeks of the intervention. Group A were given aerobic exercises and therapeutic pain neuroscience education along with conventional treatment for 45 min 3 days/week for 6 weeks, whereas participants in the Group B performed conventional exercises alone for 20 min 3 days/week for 6 weeks. Significant differences were observed in migraine disability score (P=0.003) and pain pressure threshold (P=0.039, P=0.030 and P=0.025) and improvement in forward head posture (P=0.001) between the groups after the intervention period, signifying greater improvement in the group A. QoL also improved in both the groups after intervention. Main findings of the present study suggest that the therapeutic pain neuroscience education and aerobic exercises combined with conventional treatment together maybe helpful to give better quality of life, reduced disability, increased pain pressure threshold and increased CVA to patients with migraine.

Associations of Central Sensitization-Related Symptoms with Low Back Pain-Related Factors and Work Status in Caregivers

Low back pain (LBP) is associated with psychological factors and central sensitization-related symptoms (CSSs). The relationship between CSSs, LBP-related factors, and work status in caregivers remain unclear. This multicentre, collaborative, cross-sectional study aimed to determine the association between CSS severity, LBP-related factors, and work status in caregivers with LBP. We measured LBP intensity, pain duration, pain sites, CSSs (using the Central Sensitization Inventory-9: CSI-9), psychological factors (using the Pain Catastrophizing and Pain Self-Efficacy scales), and work status (interference, amount of assistance, frequency of assistance, and work environment) in 660 caregivers. CSS severity was categorised as no (CSI-9:0−9), mild (CSI-9:10−19), or moderate/severe (CSI-9:20−36). We further performed multiple comparison analyses and adjusted the residual chi-square to reveal differences between CSS severity groups. Caregivers with more severe CSSs tended to exhibit worse LBP intensity (p < 0.01), widespread pain (p < 0.01), catastrophic thinking (p < 0.01), and pain self-efficacy (p < 0.01), and they also tended to experience work interference (p < 0.01). Caregivers without CSSs tended to receive a smaller amount of assistance with a lower frequency (p < 0.05). The number of participants with an adequate environment and equipment was significantly less in the moderate/severe CSS group (p < 0.01). Thus, our findings may suggest that CSS severity is associated with LBP intensity, widespread pain, psychological factors, and work status in caregivers.

A Mixed Comparison of Interventions for Kinesiophobia in Individuals With Musculoskeletal Pain: Systematic Review and Network Meta-Analysis

Objective

This systematic review aims to make a mixed comparison of interventions for kinesiophobia and individuals with musculoskeletal pain.

Methods

A comprehensive search strategy was conducted in the database of PubMed, MEDLINE, and Web of Science with the inclusion criteria: (1) randomized controlled design; (2) patients with musculoskeletal pain as participants; (3) treatments protocols of kinesiophobia as interventions or comparisons; (4) the score of Tampa Scale Kinesiophobia (TSK) as outcome measures. A network meta-analysis was used to synthesize the data after checking the model consistency. The risk of bias was assessed by the Cochrane Collaboration Risk of Bias Assessment Tool.

Results

Thirty-one studies were included in this review after a comprehensive search strategy with a low risk of bias and good consistency. According to the results of the network meta-analysis, a multi-modal treatment protocol had the highest probability to become the best choice in dealing with kinesiophobia caused by musculoskeletal pain, whereas psychological treatment protocols also showed a potentially positive effect on musculoskeletal pain-induced kinesiophobia.

Conclusion

Multi-modal protocols could be recommended as the preferred option when dealing with kinesiophobia caused by musculoskeletal pain. However, it is still worth mentioning that there are also potentially positive therapeutic effects of psychological interventions. Since the concept of kinesiophobia is based on the fear-avoidance model, the psychological mechanism should be paid enough attention to during treatment.

Registration Number

CRD42021286450.

Blended-Learning Pain Neuroscience Education and Exercise in High School Students With Chronic Neck Pain: A Randomized Controlled Trial

OBJECTIVE

Pain neuroscience education (PNE) and exercise have emerged as potential interventions in adolescents with chronic pain; however, very few studies have explored their effectiveness. Blended-learning approaches combining face-to-face and online educational sessions have also emerged as facilitating methods of health education. This study aimed to compare the effectiveness of exercises and PNE versus exercise alone in adolescents with chronic neck pain (NP).

METHODS

A randomized controlled trial with 6-month follow-up was conducted in 2 high schools. Over 8 weeks, a total of 127 adolescents with chronic NP were randomly allocated to either (1) perform functional and region-specific exercises, including generalized neuromuscular control, endurance, and strength exercises, as well as exercises targeting the deep neck flexor and extensor muscles and scapular stabilizer muscles; or (2) perform the same exercise-based intervention plus PNE. Pain intensity (primary outcome), disability, sleep, catastrophizing, fear of movement, self-efficacy, and knowledge of pain neuroscience were assessed at baseline, postintervention, and 6-month follow-up. Neck and scapular muscle endurance and pressure pain thresholds were assessed at baseline and postintervention. Patient's Global Impression of Change was assessed postintervention and at 6-month follow-up.

RESULTS

There was a significant decrease in pain intensity from baseline to postintervention and from baseline to follow-up in both groups, but there were no between-group differences or interactions between time and groups. These results were similar for the secondary outcomes, except for knowledge of pain neuroscience, for which a significant group and time interaction was found.

CONCLUSION

Exercise and exercise plus PNE were similarly effective in treating adolescents with chronic NP, and the results were maintained for up to 6 months. Further studies are needed to explore the effect of these interventions for longer follow-ups.

The cognitive-behavioral aspects of the Mulligan concept of manual therapy: A systematic review

Low back pain (LBP) is a common clinical problem imposing a prominent socio-economic burden. The purpose of this systematic review was to investigate the biopsychosocial effects of the Mulligan Concept (MC) of manual therapy (MT) when applied to patient's with LBP. Three researchers independently evaluated the literature quality, and completed a review on five online databases (Medline, Cochrane Library, Science Direct, ProQuest and Google Scholar) for articles published from January 1st 2010 to November 20th 2021, using a combination of free words, Wildcards and Medical Subject Headings (MESH) terms: " Mulligan mobilization " AND " back pain " OR " SNAGs." In total, 62 studies were selected for full-text reading, from which finally 6 studies were included in the present review. The results revealed that the studies where the MC of MT was applied to treat LBP mainly lacked concern regarding the effect that the intervention has on the cognitive and behavioural parameters. The ones that introduced measure outcomes for at least some parts of the cognitive behavioural components, showed that the MC has a positive effect, even though without a long-term follow-up assessment. This review summarized that the evidence of the MC on cognitive behavioural (CB) aspects of patients with LBP is controversial and scarce.

Pain Science Education Plus Exercise Therapy in Chronic Nonspecific Spinal Pain: A Systematic Review and Meta-analyses of Randomized Clinical Trials

Exercise therapy and education are recommended from several guidelines for managing symptoms in chronic nonspecific spinal pain (CNSP) patients. However, no systematic reviews have previously analyzed the effectiveness of pain science education (PSE) plus exercise therapy for managing CNSP related symptoms. Systematic searches were conducted on 10 databases looking for randomized control trials (RCTs) aimed to evaluate the effectiveness on pain, disability, kinesiophobia, and catastrophizing. Data were analyzed using random-effects meta-analyses and studies were appraised using the Cochrane ROB tool and GRADE. A total of eight RCTs (n = 622) were included in the qualitative-analysis and five were selected for meta-analysis. PSE plus exercise therapy showed improvements in pain (5RCTs: short-term: SMD: -0.53 [-0.86,-0.2]; 4RCTs: intermediate-term: SMD: -0.57 [-1.01,-0.14]; low quality), disability (4RCTs: short-term: SMD: -0.24 [-0.53,0.05]; 4RCTs: intermediate-term: SMD: -0.93 [-1.08,-0.03]; low-to-very-low quality), kinesiophobia (3RCTs: short-term: SMD: -0.7 [-1.51,0.11]; 4RCTs: intermediate-term: SMD: -0.93 [-1.57,-0.30]; moderate-to-very-low quality), and catastrophizing (2RCTs: short-term: MD: -3.26 points [-6.15,-0.37]; 3RCTs: intermediate-term: MD: -4.94 points [-8.08,-1.81]; low-to-very-low quality) compared to exercise alone. A qualitative-analysis showed improvements in the experimental group compared to multimodal physiotherapy (1RCT; low-to-very-low quality), whereas no clear benefits were reported compared to PSE alone (1RCT; very-low quality) or no intervention (1RCT; very-low quality). There is low to very-low certainty of the evidence suggesting that PSE plus exercise therapy reduces CNSP related-symptoms. PERSPECTIVE: Based on low-quality data from small samples, PSE plus exercise therapy reduces CNSP related symptoms. The evidence requires further investigation due to the limited number of studies with short follow-up periods (CRD42020168968).

Psychological interventions for chronic, non-specific low back pain: systematic review with network meta-analysis

OBJECTIVE

To determine the comparative effectiveness and safety of psychological interventions for chronic low back pain.

DESIGN

Systematic review with network meta-analysis.

DATA SOURCES

Medline, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, SCOPUS, and CINAHL from database inception to 31 January 2021.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Randomised controlled trials comparing psychological interventions with any comparison intervention in adults with chronic, non-specific low back pain. Two reviewers independently screened studies, extracted data, and assessed risk of bias and confidence in the evidence. Primary outcomes were physical function and pain intensity. A random effects network meta-analysis using a frequentist approach was performed at post-intervention (from the end of treatment to <2 months post-intervention); and at short term (≥2 to <6 months post-intervention), mid-term (≥6 to <12 months post-intervention), and long term follow-up (≥12 months post-intervention). Physiotherapy care was the reference comparison intervention. The design-by-treatment interaction model was used to assess global inconsistency and the Bucher method was used to assess local inconsistency.

RESULTS

97 randomised controlled trials involving 13 136 participants and 17 treatment nodes were included. Inconsistency was detected at short term and mid-term follow-up for physical function, and short term follow-up for pain intensity, and were resolved through sensitivity analyses. For physical function, cognitive behavioural therapy (standardised mean difference 1.01, 95% confidence interval 0.58 to 1.44), and pain education (0.62, 0.08 to 1.17), delivered with physiotherapy care, resulted in clinically important improvements at post-intervention (moderate quality evidence). The most sustainable effects of treatment for improving physical function were reported with pain education delivered with physiotherapy care, at least until mid-term follow-up (0.63, 0.25 to 1.00; low quality evidence). No studies investigated the long term effectiveness of pain education delivered with physiotherapy care. For pain intensity, behavioural therapy (1.08, 0.22 to 1.94), cognitive behavioural therapy (0.92, 0.43 to 1.42), and pain education (0.91, 0.37 to 1.45), delivered with physiotherapy care, resulted in clinically important effects at post-intervention (low to moderate quality evidence). Only behavioural therapy delivered with physiotherapy care maintained clinically important effects on reducing pain intensity until mid-term follow-up (1.01, 0.41 to 1.60; high quality evidence).

CONCLUSIONS

For people with chronic, non-specific low back pain, psychological interventions are most effective when delivered in conjunction with physiotherapy care (mainly structured exercise). Pain education programmes (low to moderate quality evidence) and behavioural therapy (low to high quality evidence) result in the most sustainable effects of treatment; however, uncertainty remains as to their long term effectiveness. Although inconsistency was detected, potential sources were identified and resolved.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019138074.

Risk Prescriptions of Strong Opioids in the Treatment of Chronic Non-Cancer Pain by Primary Care Physicians in Catalonia: Opicat Padris Project

The prescription of strong opioids (SO) for chronic non-cancer pain (CNCP) is steadily increasing. This entails a high risk of adverse effects, a risk that increases with the concomitant prescription of SO with central nervous system depressant drugs and with the use of SO for non-recommended indications. In order to examine this concomitant risk prescription, we designed a descriptive, longitudinal, retrospective population-based study. Patients aged ≥15 years with a continued SO prescription for ≥3 months during 2013-2017 for CNCP were included. Of these, patients who had received concomitant prescriptions of SO and risk drugs (gabapentinoids, benzodiazepines and antidepressants) and those who had received immediate-release fentanyl (IRF) were selected. The study included 22,691 patients; 20,354 (89.7%) patients received concomitant risk prescriptions. Men and subjects with a higher socioeconomic status received fewer concomitant risk prescriptions. Benzodiazepines or Z-drugs were prescribed concomitantly with SO in 15,883 (70%) patients, antidepressants in 14,932 (65%) and gabapentinoids in 11,267 (49%), while 483 (21.32%) patients received IRF (2266 prescriptions in total) without a baseline SO. In conclusion, our study shows that a high percentage of patients prescribed SO for CNCP received concomitant prescriptions with known risks, as well as IRF for unauthorized indications.

Trends in the Prescription of Strong Opioids for Chronic Non-Cancer Pain in Primary Care in Catalonia: Opicat-Padris-Project

In chronic non-cancer pain (CNCP), evidence of the effectiveness of strong opioids (SO) is very limited. Despite this, their use is increasingly common. To examine SO prescriptions, we designed a descriptive, longitudinal, retrospective population-based study, including patients aged ≥15 years prescribed SO for ≥3 months continuously in 2013–2017 for CNCP in primary care in Catalonia. Of the 22,691 patients included, 17,509 (77.2%) were women, 10,585 (46.6%) were aged >80 years, and most had incomes of <€18,000 per year. The most common diagnoses were musculoskeletal diseases and psychiatric disorders. There was a predominance of transdermal fentanyl in the defined daily dose (DDD) per thousand inhabitants/day, with the greatest increase for tapentadol (312% increase). There was an increase of 66.89% in total DDD per thousand inhabitants/day for SO between 2013 (0.737) and 2017 (1.230). The mean daily oral morphine equivalent dose/day dispensed for all drugs was 83.09 mg. Transdermal fentanyl and immediate transmucosal release were the largest cost components. In conclusion, there was a sustained increase in the prescription of SO for CNCP, at high doses, and in mainly elderly patients, predominantly low-income women. The new SO are displacing other drugs.

The Efficacy and Effectiveness of Education for Preventing and Treating Non-Specific Low Back Pain in the Hispanic Cultural Setting: A Systematic Review

A systematic review was conducted to assess the efficacy and effectiveness of education programs to prevent and treat low back pain (LBP) in the Hispanic cultural setting. Electronic and manual searches identified 1148 unique references. Nine randomized clinical trials (RCTs) were included in this review. Methodological quality assessment and data extraction followed the recommendations from the Cochrane Back Pain Review Group. Education programs which were assessed focused on active management (3 studies), postural hygiene (7), exercise (4) and pain neurophysiology (1). Comparators were no intervention, usual care, exercise, other types of education, and different combinations of these procedures. Five RCTs had a low risk of bias. Results show that: (a) education programs in the school setting can transmit potentially useful knowledge for LBP prevention and (b) education programs for patients with LBP improve the outcomes of usual care, especially in terms of disability. Education on pain neurophysiology improves the results of education on exercise, and education on active management is more effective than “sham” education and education on postural hygiene. Future studies should assess the comparative or summatory effects of education on exercise, education on pain neurophysiology and education on active management, as well as explore their efficiency.

Short-term impact of combining pain neuroscience education with exercise for chronic musculoskeletal pain: a systematic review and meta-analysis

ABSTRACT

Exercise and pain neuroscience education (PNE) have both been used as standalone treatments for chronic musculoskeletal pain. The evidence supporting PNE as an adjunct to exercise therapy is growing but remains unclear. The aim of this systematic review and meta-analysis was to evaluate the effect of combining PNE and exercise for patients with chronic musculoskeletal pain, when compared with exercise alone. A systematic search of electronic databases was conducted from inception to November 6, 2020. A quality effects model was used to meta-analyze outcomes where possible. Five high-quality randomized controlled studies (n = 460) were included in this review. The PEDro scale was used to assess the quality of individual studies, and Grading of Recommendations, Assessment, Development, and Evaluation analysis was conducted to determine the quality of evidence for each outcome. Meta-analyses were performed for pain intensity, disability, kinesiophobia, and pain catastrophizing using data reported between 0 and 12 weeks postintervention. Long-term outcomes (>12 weeks) were only available for 2 studies and therefore were not suitable for meta-analysis. Meta-analysis revealed a significant difference in pain (weighted mean differences, -2.09/10; 95% confidence interval [CI], -3.38 to -0.80; low certainty), disability (standardized mean difference, -0.68; 95% CI, -1.17 to -0.20; low certainty), kinesiophobia (standardized mean difference, -1.20; CI, -1.84 to -0.57; moderate certainty), and pain catastrophizing (weighted mean differences, -7.72; 95% CI, -12.26 to -3.18; very low certainty) that favoured the combination of PNE and exercise. These findings suggest that combining PNE and exercise in the management of chronic musculoskeletal pain results in greater short-term improvements in pain, disability, kinesiophobia, and pain catastrophizing relative to exercise alone.

Neuroscience Education as Therapy for Migraine and Overlapping Pain Conditions: A Scoping Review

BACKGROUND

Neuroscience education therapy (NET) has been successfully used for numerous overlapping pain conditions, but few studies have investigated NET for migraine.

OBJECTIVE

We sought to 1) review the literature on NET used for the treatment of various pain conditions to assess how NET has been studied thus far and 2) recommend considerations for future research of NET for the treatment of migraine.

DESIGN/METHODS

Following the PRISMA guideline for scoping reviews, co-author (TR), a medical librarian, searched the MEDLINE, PsychInfo, Embase, and Cochrane Central Clinical Trials Registry databases for peer-reviewed articles describing NET to treat migraine and other chronic pain conditions. Each citation was reviewed by two trained independent reviewers. Conflicts were resolved through consensus.

RESULTS

Overall, a NET curriculum consists of the following topics: pain does not equate to injury, pain is generated in the brain, perception, genetics, reward systems, fear, brain plasticity, and placebo/nocebo effects. Delivered through individual, group, or a combination of individual and group sessions, NET treatments often incorporate exercise programs and/or components of other evidence-based behavioral treatments. NET has significantly reduced catastrophizing, kinesiophobia, pain intensity, and disability in overlapping pain conditions. In migraine-specific studies, when implemented together with traditional pharmacological treatments, NET has emerged as a promising therapy by reducing migraine days, pain intensity and duration, and acute medication intake.

CONCLUSION

NET is an established treatment for pain conditions, and future research should focus on refining NET for migraine, examining delivery modality, dosage, components of other behavioral therapies to integrate, and migraine-specific NET curricula.

Exercise therapy for chronic low back pain

BACKGROUND

Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.

OBJECTIVES

The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.

SEARCH METHODS

We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.

SELECTION CRITERIA

We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.

DATA COLLECTION AND ANALYSIS

Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.

MAIN RESULTS

We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias.  Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

Pain Neuroscience Education Combined with Therapeutic Exercises Provides Added Benefit in the Treatment of Chronic Neck Pain

BACKGROUND

Chronic neck pain is common in the adult general population. Although the etiology of chronic neck pain is under debate, it is clear that chronic neck pain is multifactorial, with both physical and psychosocial contributors.

OBJECTIVE

To determine whether adding pain neuroscience education (PNE) to therapeutic exercises improved their pain-disability index, pain catastrophizing, fear-avoidance beliefs, and pain self-efficacy in subjects with chronic nonspecific neck pain.

METHODS

This study was a three-arm randomized control trial. Seventy-two patients with chronic nonspecific neck pain were allocated to three groups: therapeutic exercises alone (n = 24), combined (therapeutic exercises + PNE; (n = 24), and a control group (n = 24). Each program took place three times a week, lasting for six weeks. The disability index, pain catastrophizing, fear-avoidance beliefs, and pain self-efficacy measured by the Neck Pain and Disability Scale (NPAD), Pain Catastrophizing Scale (PCS), Fear-Avoidance Beliefs Questionnaire (FABQ), and Pain Self-Efficacy Questionnaire (PSEQ), respectively. Participants were assessed before and after the six-week intervention, and there was no further follow-up.

RESULTS

For the outcomes NPAD, PSC, and FABQ, combined intervention demonstrated more significant improvements than therapeutic exercises alone (p ≤ 0.05), whereas no differences were observed between the two intervention groups for PSEQ (p = 0.99). In addition, significant differences were favoring experimental groups versus control for all outcomes (p ≤ 0.001).

CONCLUSION

Therapeutic exercises combined with pain neuroscience education reduced the pain-disability index, pain catastrophizing, and fear-avoidance beliefs more than therapeutic exercises alone in patients with chronic neck pain. For pain self-efficacy, there was no statistically significant difference between the two intervention groups; however, the combined group had a more significant effect than therapeutic exercises alone. Further studies with longer periods and follow-up are required.

Lumbar spondylolisthesis: STATE of the art on assessment and conservative treatment

INTRODUCTION

There is weak relationship between the presence of lumbar spondylolisthesis [SPL] and low back pain that is not always associated with instability, either at the involved lumbar segment or at different spinal levels. Therefore patients with lumbar symptomatic SPL can be divided into stable and unstable, based on the level of mobility during flexion and extension movements as general classifications for diagnostic and therapeutic purposes. Different opinions persist about best treatment (conservative vs. surgical) and among conservative treatments, on the type, dosage, and progression of physical therapy procedures.

PURPOSE AND IMPORTANCE TO PRACTICE

The aim of this Masterclass is to provide clinicians evidence-based indications for assessment and conservative treatment of SPL, taking into consideration some subgroups related to specific clinical presentations.

CLINICAL IMPLICATIONS

This Masterclass addresses the different phases of the assessment of a patient with SPL, including history, imaging, physical exam, and questionnaires on disability and cognitive-behavioral components. Regarding conservative treatment, self- management approaches and graded supervised training, including therapeutic relationships, information and education, are explained. Primary therapeutic procedures for pain control, recovery of the function and the mobility through therapeutic exercise, passive mobilization and antalgic techniques are suggested. Moreover, some guidance is provided on conservative treatment in specific clinical presentations (lumbar SPL with radiating pain and/or lumbar stenosis, SPL complicated by other factors, and SPL in adolescents) and the number/duration of sessions.

FUTURE RESEARCH PRIORITIES

Some steps to improve the diagnostic-therapeutic approach in SPL are to identify the best cluster of clinical tests, define different lumbar SPL subgroups, and investigate the effects of treatments based on that classification, similarly to the approach already proposed for non-specific LBP.

Effectiveness of perioperative pain science education on pain, psychological factors and physical functioning: A systematic review

OBJECTIVE

To synthesize the evidence on the effectiveness of pain science education on pain, psychological factors and physical functioning in adults who underwent surgery.

DATA SOURCES

A systematic literature search of English articles using PubMed/Medline, Embase, Web of Science Core Collection, and Cochrane Library.

REVIEW METHODS

The search strategy was constructed as follows: (((pain) AND (education)) OR (pain education)) AND (surgery). Only controlled quantitative studies in adults reporting outcome(s) on pain, psychological factors and/or physical functioning were included. Risk of bias was assessed using the Cochrane risk of bias tools. P-values and corresponding effect sizes for interaction-effect (time × group) portrayed the difference in change over time between groups were of interest. The last search was conducted on February 28, 2021.

RESULTS

Nine papers (n = 1078) were deemed eligible for this review. Two randomized controlled trials showed significant interaction effects. Breast cancer patients who had received one preoperative pain science education session showed a significant increase in postoperative pain compared to controls (P-value = 0.0394). Furthermore, psychological factors (pain catastrophizing and kinesiophobia) decreased in participants who had received pain science education before total knee arthroplasty, while this was not the case in the control group (P-value < 0.001, ƞ2p:0.11).

CONCLUSIONS

Overall, pain science education did not result in any significant postoperative effects on pain, psychological factors and/or physical functioning compared to controls. There is currently no strong evidence for the implementation of pain science education in the perioperative period.Registration number: PROSPERO: ID 161267, registration number CRD42020161267.

Effectiveness of a structured group intervention based on pain neuroscience education for patients with fibromyalgia in primary care: A multicentre randomized open-label controlled trial

Background

There has been increased interest in pain neuroscience education (PNE) as a therapeutic approach for the management of fibromyalgia (FM).

Methods

A multicentre randomized, open‐label, controlled trial was conducted to assess the effectiveness of a structured group intervention based on PNE in patients with FM. A total of 139 patients were included in the study and randomized to the intervention group (7 group sessions of education in neurobiology of pain) or to the control group (treatment as usual only). The primary outcome was the improvement of functional status and pain measured with the Fibromyalgia Impact Questionnaire (FIQ), and secondary outcomes were the reduction in the impact of pain and other symptoms (catastrophizing, anxiety and depression) and number of patients reaching no worse than moderate functional impairment (FIQ score <39). Differences between groups were calculated by linear mixed‐effects (intention‐to‐treat approach) and mediational models through path analyses.

Results

At 1 year, improvements in FIQ scores were higher in the intervention group with moderate or high effect size, and decreases of ≥20% in 69.1% of patients (20.9% in the control group) and of ≥50% in 39.7% (4.5% in the control group). Also, 52.9% of patients had a FIQ <39 points (13.4% in the control group).

Conclusions

In this sample of patients with FM, the improvement in quality of life and control of symptoms obtained by adding a PNE intervention showed promising results, equalling or surpassing previously reported outcomes.

Significance

A structured group intervention based on pain neuroscience education for 1 year in patients with fibromyalgia was associated with significant amelioration of the impact of the disease on scores of the Fibromyalgia Impact Questionnaire, the Health Assessment Questionnaire, the Hospital Anxiety and Depression Scale, the Pain Catastrophizing Scale and the Polysymptomatic Distress Scale as compared with only treatment as usual. These findings are clinically relevant considering the challenges posed by fibromyalgia to clinicians and patients alike.

Effects of 6-Month Multimodal Physical Exercise Program on Bone Mineral Density, Fall Risk, Balance, and Gait in Patients with Alzheimer's Disease: A Controlled Clinical Trial

We aimed to determine the short- and medium-term effects of a multimodal physical exercise program (MPEP) on bone health status, fall risk, balance, and gait in patients with Alzheimer’s disease. A single-blinded, controlled clinical trial was performed where 72 subjects were allocated in a 3:1 ratio to an intervention group (IG; n = 53) and control group (CG; n = 19), where the IG’s subjects were admitted to live in a State Reference Center of Alzheimer’s disease, which offers the targeted exercise program, while the CG’s subjects resided in independent living. A multidisciplinary health team assessed all patients before allocation, and dependent outcomes were again assessed at one, three, and six months. During the study, falls were recorded, and in all evaluations, bone mineral density was measured using a calcaneal quantitative ultrasound densitometer; balance and gait were measured using the performance-oriented mobility assessment (POMA), the timed up and go test (TUG), the one-leg balance test (OLB), and the functional reach test (FR). There were no differences between groups at baseline for all outcome measures. The prevalence of falls was significantly lower in the IG (15.09%) than in the CG (42.11%) (χ² = 5.904; p = 0.015). We also found that there was a significant time*group interaction, with a post hoc Šidák test finding significant differences of improved physical function, especially in gait, for the IG, as assessed by POMA-Total, POMA-Gait, and TUG with a large effect size (ƞ²p = 0.185–0.201). In balance, we found significant differences between groups, regardless of time, and a medium effect size as assessed by POMA-Balance and the OLB (ƞ²p = 0.091–0.104). Clinically relevant effects were observed, although without significant differences in bone health, with a slowing of bone loss. These results show that a multimodal physical exercise program reduces fall risk and produces an improvement in gait, balance, and bone mineral density in the short and medium term in institutionalized patients with Alzheimer’s disease.

Effect of pain neuroscience education and exercise on presenteeism and pain intensity in health care workers: A randomized controlled trial

OBJECTIVES

Decreased workforce productivity has a significant economic impact on healthcare systems. Presenteeism, the practice of working at reduced potential, is more harmful than absenteeism. Present workers most often experience musculoskeletal pain that is not mitigated by general exercise or stretching. We aimed to assess whether a regimen of pain neuroscience education (PNE) and exercise tailored to individual healthcare workers could reduce presenteeism and improve productivity.

METHODS

An independent investigator randomized 104 medical professionals into two groups (intervention and control). The control group received general feedback after answering a questionnaire, while the intervention group received a 6-month plan of exercises and PNE created by a physical therapist with 10 years of experience. Our primary outcome was the scores of the Japanese version of the World Health Organization Health and Work Performance Questionnaire (WHO-HPQ) to investigate presenteeism; and our secondary outcomes were pain intensity, widespread pain index (WPI), and EuroQol 5-dimension (EQ5D-5L).

RESULTS

In the intervention group, post intervention, we observed significant improvement in presenteeism, pain intensity, WPI, physical and psychological stress, and EQ5D-5L (P < .05). In the control group, we noted significant improvement only in the physical and psychological stress post intervention (P < .05). The results showed significant between-group differences in presenteeism post-intervention (P < .05).

CONCLUSION

We demonstrated that a combination of PNE and exercise decreases presenteeism of healthcare workers. Our findings will help healthcare facilities carry out better employee management and ensure optimal productivity.

Effectiveness of a Multicomponent Treatment for Fibromyalgia Based on Pain Neuroscience Education, Exercise Therapy, Psychological Support, and Nature Exposure (NAT-FM): A Pragmatic Randomized Controlled Trial

A recent study (FIBROWALK has supported the effectiveness of a multicomponent treatment based on pain neuroscience education (PNE), exercise therapy (TE), cognitive behavioral therapy (CBT), and mindfulness in patients with fibromyalgia. The aim of the present RCT was: (a) to analyze the effectiveness of a 12-week multicomponent treatment (nature activity therapy for fibromyalgia, NAT-FM) based on the same therapeutic components described above plus nature exposure to maximize improvements in functional impairment (primary outcome), as well as pain, fatigue, anxiety-depression, physical functioning, positive and negative affect, self-esteem, and perceived stress (secondary outcomes), and kinesiophobia, pain catastrophizing thoughts, personal perceived competence, and cognitive emotion regulation (process variables) compared with treatment as usual (TAU); (b) to preliminarily assess the effects of the nature-based activities included (yoga, Nordic walking, nature photography, and Shinrin Yoku); and (c) to examine whether the positive effects of TAU + NAT-FM on primary and secondary outcomes at post-treatment were mediated through baseline to six-week changes in process variables. A total of 169 FM patients were randomized into two study arms: TAU + NAT-FM vs. TAU alone. Data were collected at baseline, at six-week of treatment, at post-treatment, and throughout treatment by ecological momentary assessment (EMA). Using an intention to treat (ITT) approach, linear mixed-effects models and mediational models through path analyses were computed. Overall, TAU + NAT-FM was significantly more effective than TAU at posttreatment for the primary and secondary outcomes evaluated, as well as for the process variables. Moderate-to-large effect sizes were achieved at six-weeks for functional impairment, anxiety, kinesiophobia, perceived competence, and positive reappraisal. The number needed to treat (NNT) was 3 (95%CI = 1.6-3.2). The nature activities yielded an improvement in affective valence, arousal, dominance, fatigue, pain, stress, and self-efficacy. Kinesiophobia and perceived competence were the mediators that could explain a significant part of the improvements obtained with TAU + NAT-FM treatment. TAU + NAT-FM is an effective co-adjuvant multicomponent treatment for improving FM-related symptoms.

Effectiveness of a Physical Therapeutic Exercise Programme for Caregivers of Dependent Patients: A Pragmatic Randomised Controlled Trial from Spanish Primary Care

Female family caregivers (FFCs) constitute one of the basic supports of socio-health care for dependence in developed countries. The care provided by FFCs may impact their physical and mental health, negatively affecting their quality of life. In order to alleviate the consequences of providing care on FFCs, the Spanish Public Health System has developed the family caregiver care programme (FCCP) to be applied in primary care (PC) centres. The effectiveness of this programme is limited. To date, the addition of a physical therapeutic exercise (PTE) programme to FCCP has not been evaluated. A randomised multicentre clinical trial was carried out in two PC centres of the Spanish Public Health System. In total, 68 FFCs were recruited. The experimental group (EG) performed the usual FCCP (4 sessions, 6 h) added to a PTE programme (36 sessions in 12 weeks) whereas the control group performed the usual FCCP performed in PC. The experimental treatment improved quality of life (d = 1.17 in physical component summary), subjective burden (d = 2.38), anxiety (d = 1.52), depression (d = 1.37) and health-related physical condition (d = 2.44 in endurance). Differences between the groups (p < 0.05) were clinically relevant in favour of the EG. The experimental treatment generates high levels of satisfaction.