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.

Effectiveness of Pain Neuroscience Education in Patients with Fibromyalgia: A Systematic Review and Meta-Analysis

PURPOSE

To assess the effects of pain neuroscience education (PNE) on patients with fibromyalgia (FM) in terms of pain intensity, fibromyalgia impact, anxiety, and pain catastrophizing.

METHODS

A systematic review and meta-analysis of randomized controlled trials was conducted. Standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated with RStudio software for relevant outcomes and were pooled in a meta-analysis using the random effects model.

RESULTS

A total of 8 studies were included. The meta-analysis showed statistically significant differences in the pain intensity with a moderate clinical effect in 7 studies in the post-intervention assessment (SMD:-0.76; 95% CI:-1.33- -0.19; p < 0.05) with evidence of significant heterogeneity (p < 0.05, I2=92%) but not in fibromyalgia impact, anxiety, and pain catastrophizing (p > 0.05). Regarding the follow-up assessment, only the fibromyalgia impact showed significant improvements with a very small clinical effect in 9 studies (SMD:-0.44; 95% CI:-0.73- -0.14; p < 0.05) with evidence of significant heterogeneity (p < 0.05, I2 = 80%). Applying a sensitivity analysis with the PNE face-to-face interventions, the meta-analysis showed a significant decrease of pain intensity with a moderate clinical effect at post-intervention and follow-up without evidence of significant heterogeneity (p < 0.05, I2=10%).

CONCLUSIONS

There is low quality evidence that in patients with FM, PNE can decrease the pain intensity post-intervention and also the fibromyalgia impact in the follow-up. However, it appears that PNE showed no effect on anxiety and pain catastrophizing.

Effectiveness of a Multicomponent Treatment Based on Pain Neuroscience Education, Therapeutic Exercise, Cognitive Behavioral Therapy, and Mindfulness in Patients With Fibromyalgia (FIBROWALK Study): A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of a 12-week multicomponent treatment based on pain neuroscience education, therapeutic exercise, cognitive behavioral therapy, and mindfulness-in addition to treatment as usual-compared with treatment as usual only in patients with fibromyalgia.

METHODS

This randomized controlled trial involved a total of 272 patients who were randomly assigned to either multicomponent treatment (n = 135) or treatment as usual (n = 137). The multicomponent treatment (2-hour weekly sessions) was delivered in groups of 20 participants. Treatment as usual was mainly based on pharmacological treatment according to the predominant symptoms. Data on functional impairment using the Revised Fibromyalgia Impact Questionnaire as the primary outcome were collected as were data for pain, fatigue, kinesiophobia, physical function, anxiety, and depressive symptoms (secondary outcomes) at baseline, 12 weeks, and, for the multicomponent group only, 6 and 9 months. An intention-to-treat approach was used to analyze between-group differences. Baseline differences between responders (>20% Revised Fibromyalgia Impact Questionnaire reduction) and nonresponders also were analyzed, and the number needed to treat was computed.

RESULTS

At posttreatment, significant between-group differences with a large effect size (Cohen d > 0.80) in favor of the multicomponent treatment were found in functional impairment, pain, kinesiophobia, and physical function, whereas differences with a moderate size effect (Cohen d > 0.50 and <0.80) were found in fatigue, anxiety, and depressive symptoms. Nonresponders scored higher on depressive symptoms than responders at baseline. The number needed to treat was 2 (95% CI = 1.7-2.3).

CONCLUSION

Compared with usual care, there was evidence of short-term (up to 3 months) positive effects of the multicomponent treatment for fibromyalgia. Some methodological shortcomings (eg, absence of follow-up in the control group and monitoring of treatment adherence, potential research allegiance) preclude robust conclusions regarding the proposed multicomponent program.

IMPACT

Despite some methodological shortcomings in the design of this study, the multicomponent therapy FIBROWALK can be considered a novel and effective treatment for patients with fibromyalgia. Physical therapists should detect patients with clinically relevant depression levels prior to treatment because depression can buffer treatment effects.

LAY SUMMARY

Fibromyalgia is prevalent and can be expensive to treat. This multicomponent treatment could significantly improve the core symptoms of fibromyalgia compared with usual treatment.

"A journey to learn about pain": the development and validation of a comic book about pain neuroscience education for children

BACKGROUND

Pain education resources for children using appropriate language and illustrations remain scarce.

OBJECTIVES

We aimed to summarize the development process and testing for face and content validity of a structured comic book about pain education for children.

METHODS

A first draft of a comic book was developed (Portuguese and English) based on pain education concepts. Experts in pediatric pain from different countries analyzed content, objectives, language, illustrations, layout, motivation, and cultural adjustment. A third draft developed in Portuguese considering experts' suggestions was presented to children and parents in Brazil. The total adequacy score was calculated from the sum of the scores obtained in each domain, divided by the maximum total score. Descriptive analysis is presented.

RESULTS

The expert panel was composed of 11 (64.7%) physical therapists, and 6 (35.3%) psychologists. The total adequacy score (0-100%) was 87.74%. The third draft version of the comic book was presented to 28 children and the final version was presented to 16 children with a mean age of 9.6 years. Children were totally satisfied (n=4; 26.7%) or satisfied (n=9; 56.2%) with the story of the comic book. The readability of the comic book was considered suitable for grades 4 to 6 educational level.

CONCLUSION

The comic book "A Journey to Learn about Pain" was validated for face and content validity by the expert panel and the Brazilian target population. This comic book is available in Portuguese and English and can be a potentially useful resource for children.

A case report

Introduction: Postherpetic neuralgia (PHN) is a complex neuropathic painful condition in which pain is a direct consequence of the response to peripheral nerve damage experienced during herpes zoster attack. PHN is the most common chronic complication of herpes zoster and it causes considerable suffering, affecting the physical functioning and psychological well-being of patients. Objective: To describe the effect of a conservative treatment using pain neuroscience education (PNE) and transcutaneous electrical nerve stimulation (TENS) in a patient with trigeminal PHN. Case Description: A 67-year-old woman sought care for pain, dysfunction, and sensory loss in the left jaw. The assessment included: 1) pain, using the numerical pain rating scale (NPRS), pressure pain threshold (PPT), Douleur Neuropathique 4 (DN4), McGill Pain Questionnaire (MPQ), Graded Chronic Pain Scale (GCPS), and classic body charts of the cranial region; 2) somatosensory function, by means of mechanical detection threshold (MDT) and pressure pain threshold (PPT); 3) jaw function, using the Jaw Functional Limitation Scale-20 (JFLS-20); and 4) psychosocial features, by means of the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorders Questionnaire-7 (GAD-7). Treatment consisted of 12 sessions of PNE and TENS. Outcomes: After treatment, a clinically significant improvement in NPRS, DN4, MDT, GCPS, and PHQ-9 was observed. Conclusion: In this case report, a treatment based on the combination of PNE and TENS seemed to have contributed to improving pain, sensory abnormalities, and jaw function. Psychosocial factors also showed a trend to improve after the treatment.

Pain neuroscience education on YouTube

OBJECTIVES

The Internet in general, and YouTube in particular, is now one of the most popular sources of health-related information. Pain neuroscience education has become a primary tool for managing persistent pain, based in part on the discovery that information about pain can change pain. Our objective was to examine the availability, characteristics, and content of YouTube videos that address the neuroscience of pain.

METHODS

We conducted a systematic review of videos on YouTube using the search terms "pain education", "what is pain", and "pain brain" in January 2018. Videos were included if they were in English, were under 10 minutes long, and included information on the neuroscience of pain. Videos were coded for (i) descriptive characteristics (e.g., number of views, duration on YouTube), (ii) source and style, (iii) whether or not they addressed seven pre-determined target concepts of pain neuroscience education (e.g., 'Pain is not an accurate marker of tissue state'), and (iv) how engaging they were.

RESULTS

We found 106 unique videos that met the inclusion criteria. The videos ranged from having four views to over five million views (Mdn = 1,163 views), with the three most highly viewed videos accounting for 75% of the total views. Animated videos were much more highly viewed than non-animated videos. Only a small number of videos had been posted by a clearly-identifiable reputable source such as an academic or medical institution (10%), although a number of videos were posted by healthcare professionals and professional medical societies. For a small number of videos (7%), the source was unclear. We found 17 videos that addressed at least one target concept of pain neuroscience science education, only nine of which were considered to be at least somewhat engaging. The target concept 'Pain is a brain output' was considered to be well addressed by the most videos (N = 11), followed by 'Pain is a protector' (N = 10). We found only one video that adequately addressed all seven target concepts of pain neuroscience education.

DISCUSSION

YouTube contains a variety of videos that practitioners, patients, and families may view to access pain neuroscience education information. A small portion of these videos addressed one or more target concepts of pain neuroscience education in an engaging manner. It is yet to be determined to what extent patients are able to learn information from these videos, to what extent the videos promote behavior change, and thus to what extent the videos may be useful for clinical practice.

Development and feasibility testing of a Pain Neuroscience Education program for children with chronic pain: treatment protocol

BACKGROUND

Current treatment for adults with chronic pain often includes Pain Neuroscience Education (PNE) to make people understand the nature underlying their pain and thus provides a clear rational for a biopsychosocial approach. Despite recommendations to use Pain Neuroscience Education as well in children with chronic pain, a specific program, tailored to children aged 6-12 years is lacking.

OBJECTIVES

The aim of this study was to develop a Pain Neuroscience Education program for children with chronic pain and test its feasibility.

METHODS

First the internet and scientific literature was searched for sources (e.g., books, videos, etc.) that might be supportive in teaching children about the neurophysiology of pain. Based on this content, we developed a Pain Neuroscience Education program for children, 'PNE4Kids', which was tested for feasibility in three groups of healthy children (n=18; 9 girls and 9 boys) aged between 6 and 12 years old.

RESULTS AND CONCLUSIONS

This paper provides both scientists and clinicians with a specific program to explain the neurophysiology of pain to children with chronic pain, since it is past high time to use a modern neuroscience approach in this vulnerable population. Further research should examine the effectiveness of this developed PNE4Kids program on pain-related outcomes in children with chronic pain. Registration number: NCT02880332 (https://clinicaltrials.gov/ct2/show/NCT02880332).