Pain Physiology Education Improves Pain Beliefs in Patients With Chronic Fatigue Syndrome Compared With Pacing and Self-Management Education: A Double-Blind Randomized Controlled Trial

[An instrument to assess biopsychosocial pain concepts in adults : Development and evaluation by experts]

BACKGROUND

The biopsychosocial model is fundamental for the understanding and treatment of chronic pain; however, little research has focused on whether those affected show a biopsychosocial understanding. The multidimensional questionnaire Biopsychosocial Pain Concept Matrix (BiPS matrix) is presented. The conception of the BiPS matrix is based on the biological, psychological and social areas as well as on the common sense model of self-regulation with five dimensions: (1) type of disorder, (2) assumptions on the causes, (3) consequences, (4) duration of the disease and (5) possibilities for control and treatment.

OBJECTIVE

The present study aims to examine the content relevance and comprehension of the areas, dimensions and items, including the use of the BiPS matrix with children by interdisciplinary expert ratings. The questionnaire can be perspectively used by treating professionals for diagnostic purposes.

METHOD

In an online study 17 experts were questioned. In addition to descriptive statistics, comments were evaluated using qualitative content analysis according to Mayring.

RESULTS

All experts rated the assessment of pain concepts with the BiPS matrix as well as the areas and dimensions as very relevant. With respect to the items, suggestions were made mainly regarding the wording of the items and adjustments for children.

DISCUSSION

From an expert point of view the BiPS matrix represents a relevant instrument. Further research on the psychometric properties of the BiPS matrix in adults and children is indicated. In addition, the BiPS matrix can also be used to investigate pain concepts of medical and psychotherapeutic professional groups to demonstrate the biopsychosocial understanding of pain and the associated treatment options.

Risk-stratified Care Improves Pain-related Knowledge and Reduces Psychological Distress for Low Back Pain: A Secondary Analysis of a Randomized Trial

BACKGROUND

A number of efforts have been made to tailor behavioral healthcare treatments to the variable needs of patients with low back pain (LBP). The most common approach involves the STarT Back Screening Tool (SBST) to triage the need for psychologically informed care, which explores concerns about pain and addresses unhelpful beliefs, attitudes, and behaviors. Such beliefs that pain always signifies injury or tissue damage and that exercise should be avoided have been implied as psychosocial mediators of chronic pain and can impede recovery. The ability of physical therapy interventions guided by baseline stratification for risk of persistent LBP or related functional limitations to improve unhelpful pain beliefs has not been well assessed. Because treatments are aimed at addressing these beliefs, understanding a bit more about the nature of beliefs about pain (for example, attitudes and knowledge) might help us understand how to better tailor this care or even our risk-stratification approaches for future treatment of patients with LBP.

QUESTIONS/PURPOSES

(1) Did patients assigned to receive risk-stratified care score higher on an assessment of pain science knowledge? (2) Did patients assigned to receive risk-stratified care have fewer unhelpful attitudes related to pain? (3) Did patients assigned to receive risk-stratified care have less pain-associated psychological distress? (4) Regardless of intervention received, is baseline SBST risk category (low, medium, or high) associated with changes in attitudes and knowledge about pain?

METHODS

This is a secondary analysis of short-term changes in pain beliefs following the 6-week treatment phase of a randomized controlled trial that examined the effectiveness of a risk-stratified physical therapy intervention on pain-related disability at 1 year. Between April 2017 and February 2020, a total of 290 patients in the Military Health System seeking primary care for LBP were enrolled in a trial comparing a behavioral-based intervention to usual care. The intervention involved psychologically informed physical therapy using cognitive behavioral principles and included tailored education, graded exercise, and graded exposure. Individuals assigned to usual care followed treatment plans set forth by their primary care provider. Thirty-one patients were removed from Optimal Screening for Prediction of Referral and Outcome Yellow Flag (OSPRO-YF) tool analyses due to missing assessments at 6 weeks (n = 15 intervention; n = 16 usual care). This resulted in 89% (259 of 290) of participants included for secondary analysis, with no difference in baseline demographic characteristics between groups. The usual-care group comprised 50% of the total study group (129 of 259), with a mean age of 34 ± 9 years; 67% (87 of 129) were men. The risk-stratified care group comprised 50% (130 of 259) of the total study group, with a mean ± SD age of 35 ± 8 years; 64% (83 of 130) were men. Six additional individuals were removed from Survey of Pain Attitudes harm scale (SOPA-h) and revised Neurophysiology of Pain Questionnaire (rNPQ) analyses for missing baseline data (n = 1 intervention) and 6-week data (n = 2 intervention; n = 3 usual care). The rNPQ captured current pain science knowledge, the SOPA-h examined patient attitudes about pain (the extent of beliefs that pain leads to damage and that movement is harmful), and the OSPRO-YF assessed patients for yellow flag clinical markers of pain-related psychological distress across 11 constructs within domains of negative mood, fear avoidance, and positive affect/coping indicative of elevated vulnerability and decreased resilience. Outcomes were assessed at baseline and 6 weeks, and data were analyzed per protocol. We assessed between-group differences at 6 weeks using linear mixed-effects models of pain attitudes and knowledge and related distress, controlling for age, gender, and baseline pain. Regardless of treatment group, we also analyzed differences in rNPQ and SOPA-h scores at 6 weeks based on SBST risk category (low versus medium or high) using generalized linear (Gaussian) regression models.

RESULTS

Risk-stratified treatment was associated with improvements in pain knowledge (rNPQ mean difference 6% [95% confidence interval (CI) 1% to 11%]; p = 0.01) and a reduction in indicators of pain-associated psychological distress (OSPRO-YF mean difference -1 [95% CI -2 to 0]; p = 0.01) at 6 weeks compared with usual care. There was no difference between groups for SOPA-h score at 6 weeks (mean difference -0.2 [95% CI -0.3 to 0.0]; p = 0.09). Patients with medium- or high-risk scores on the SBST, regardless of intervention, improved slightly more on SOPA-h (β = -0.31; p < 0.01) but not rNPQ (β = 0.02; p = 0.95) than those scoring low risk.

CONCLUSION

Patients receiving risk-stratified care showed small improvements in pain knowledge and reductions in pain-related psychological distress at 6 weeks, immediately after intervention, compared with usual care. Implementation of this risk-stratified care approach for LBP was able to change patients' perceptions about pain and reduce some of their psychological distress beyond what was achieved by usual care in this setting. As these factors are believed to favorably mediate treatment outcomes, future studies should investigate whether these improvements persist over the long term, determine how they influence clinical outcomes, and explore alternatives for risk stratification and treatment to elicit greater improvements.Level of Evidence Level III, therapeutic study.

A Randomized, Double-Blind, Controlled Trial Protocol for Therapeutic Neuroscience Education in Chronic Migraine Patients: A Clinical-Neurophysiological Combined Study Design

Chronic migraine (CM) is a highly disabling condition, affecting about 2% of the global population. Non-pharmacological treatments can be optimal for their non-invasive nature. This prospective, randomized, double-blind, controlled trial aimed to test the efficacy of therapeutic neuroscience education (TNE) in CM. Early response biomarkers were also evaluated. A total of 80 CM patients were consecutively enrolled and randomly allocated to TNE or a general education program. Treatment effectiveness was evaluated at baseline (T1) and 2 months after the end of treatment (T4). We collected the responses to disability and comorbidity questionnaires at the start (T1) and end of treatment (T3, 10 weeks after start). Early response biomarkers were evaluated at screening (T0) and mid-way through the process (T2, 5 weeks after start). We expected that TNE would provide a greater benefit than the general education program, which served as the primary outcome of this study. We also expected that a change in clinical and neurophysiological measures could potentially occur, reflecting plasticity-induced reorganization and predicting clinical response. This is the first study selectively exploring the effect of TNE as a standalone treatment for CM. A new, effective treatment regime without interactions with other medication could be of great interest as an addition to migraine therapeutic strategies.

Effectiveness of pain neuroscience education, motivational interviewing and cognition targeted exercise therapy in patients with chronic neck pain: protocol for a multicentre randomised controlled trial (the COGMO-AP study)

INTRODUCTION

In primary care, the prevalence of neck pain has increased substantially. Evidence regarding treatment of chronic neck pain (CNP) is scarce, and its effectiveness is not entirely proven in different stages of chronicity, nor for different types of cervical disorders. The goal of this study is to evaluate the effectiveness of a complex intervention (COGMO intervention) compared with usual practice in primary care physiotherapy to improve neck pain intensity, severity and disability in patients with CNP.

METHODS AND ANALYSIS

Design: a pragmatic cluster-randomised clinical trial design with a 12-month follow-up.

SETTING

primary care.

PARTICIPANTS

physiotherapists as randomisation unit, and patients as analysis unit.

INCLUSION CRITERIA

individuals aged 18 to 65 years suffering from moderate to severe CNP. Sample size expected: 142 patients. Recruitment: patients referred from primary care physicians to physiotherapy.

INTERVENTION

pain neuroscience education (PNE), motivational interviewing (MI) and cognition targeted exercise therapy (CTE) compared with the standard treatment in primary care.

OUTCOMES

the main variable is reduction in pain intensity; secondary variables include pain severity, conditioned pain modulation, temporal summation, neck disability, fear/avoidance behaviour, kinesiophobia, catastrophising, therapeutic alliance and quality of life. Sociodemographic information and adherence to the intervention will be recorded.

DATA COLLECTION

baseline, and follow-up at 3, 6 and 12 months.

ANALYSIS

it will follow intention-to-treat principles, and difference in percentage of subjects achieving success on the primary endpoint at 12 months. A model with multilevel analysis will be adjusted through logistic regression (being the dependent variable pain intensity, and the independent, the intervention).

ETHICS AND DISSEMINATION

Ethical approval has been awarded by the Regional Ethics Committee of Madrid (code: COGMO-AP) and the primary health care central commission of research (code: 20210011). The results of the study will be disseminated through international peer-reviewed journals, international conferences, press and social media.

TRIAL REGISTRATION NUMBER

NCT05785455.

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 a pain science education programme in middle school students: a randomised controlled trial

Introduction

Chronic pain in childhood is a prevalent issue affecting approximately 20% of young people aged 8-16 years. This condition negatively impacts their quality of life, as well as their physical, psychological, and social functioning. In recent years, Pain Science Education has emerged as a promising strategy to enhance the conceptualization of pain and mitigate maladaptive pain-related behaviours in children and teenagers. The primary aim of this study is to assess the effectiveness of the Pain Science Education programme called "Learning Pain" in improving the conceptualization of pain amongst 11-13-year-old children enrolled in their first year of middle school.

Materials and methods

A randomised controlled trial with single-blind parallel groups was conducted. Five participating institutes were randomly assigned to either the experimental group, which received the Pain Science Education intervention through the "Learning Pain" programme consisting of two sessions spaced 1 month apart, or the control group, which underwent only study assessments. Both groups underwent initial assessment and follow-up evaluations at 1 month (short term), 7 months (medium-term), and 13 months (long-term). The main outcome measure was the conceptualization of pain, assessed using the Conceptualization of Pain Questionnaire (COPAQ).

Results

The "Learning Pain" programme, a specific Pain Science Education intervention, demonstrated effectiveness in improving the conceptualization of pain at 1, 7, and 13 months follow-up assessments.

Discussion

The "Learning Pain" programme, a specific Pain Science Education intervention, enhances the conceptualization of pain in adolescents aged 11-13 years over short, medium, and long-term periods.

Enhancing pediatric pain management in Turkey: A modified Delphi study on culturally adapted pain neuroscience education for chronic pain in children

BACKGROUND

Pain Neuroscience Education (PNE) is a commonly used technique applied by physical therapists in the rehabilitation of chronic pain.

OBJECTIVE

The aim of this study was to culturally adapt an existing PNE for children with chronic pain (PNE4Kids) to Turkish children with chronic pain (PNE4Kids-Turkish).

METHODS

A three-round modified Delphi-study was conducted between September 2023 and February 2024. Experts completed questionnaire with 5 items to elicit demographic data and 16 closed and 7 open-ended questions to assess relevance of information, feasibility of stories, visual information, and clarity of message in the 4 main areas of 'normal pain biology', 'pain modulation', 'chronic pain, adaptations, central sensitization', and 'the application and implications of PNE4Kids. MAXQDA software was used for qualitative analysis of open-ended questions. A total of 38 experts (mean age: 36.6 ± 9.05 years, 6 male, 32 female) were recruited for this study.

RESULTS

The results of the first round indicated that 84-100 % of Delphi experts strongly agreed or agreed on the relevance of information, feasibility of stories, visual information, and clarity of message in respect of the 4 main areas. During second and third round, an acceptable degree of agreement with clinical usefulness of PNE4Kids-Turkish materials was obtained.

CONCLUSIONS

PNE4Kids was culturally adapted for Turkish children suffering from chronic pain. The findings of this study mainly highlight the viewpoints of the experts.

IMPLICATION TO PRACTICE

This is the first study to have developed and culturally adapted the PNE4Kids for Turkish children with chronic pain. The PNE4Kids-Turkish is crucial, valuable, helpful, and understandable for Turkish children with chronic pain. In addition, the PNE4Kids-Turkish has the potential to close the gap in research and clinical areas for Turkish children with chronic pain.

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.

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.

Effectiveness of in-group versus individually administered pain neuroscience education on clinical and psychosocial outcomes in patients with chronic low back pain: randomized controlled study protocol

Objective

(1) This trial will compare the clinical and psychosocial effectiveness of in-group and individually pain neuroscience education (PNE) in patients with chronic low back pain (CLBP). In addition, (2) the influence of social determinants of health on post-treatment results will be analyzed.

Methods

A three-arm randomized controlled trial will be conducted. Sixty-nine participants with CLBP will be recruited in a 1:1:1 ratio. Participants, assessor, and statistician will be blinded to group assignment. The PNE intervention will be adapted to the context of the participants. An experimental group (n = 33) will receive PNE in an in-group modality, the other experimental group (n = 33) will receive PNE in an individually modality and the control group (n = 33) will continue with usual care. Additionally, participants will be encouraged to stay active by walking for 20-30 min 3-5 times per week and will be taught an exercise to improve transversus abdominis activation (bracing or abdominal following). The outcome measures will be fear avoidance and beliefs, pressure pain threshold, pain self-efficacy, catastrophizing, pain intensity, and treatment expectation. Outcome measures will be collected at one-week before intervention, immediately post-intervention, and four-weeks post-intervention.

Conclusion

The innovative approach of PNE oriented to fear beliefs proposed in this study could broaden the application strategies of this educational therapeutic modality. Impact. Contextualized PNE delivered by physical therapist could be essential to achieve a good cost-effectiveness ratio of this intervention to improve the clinical condition of people with CLBP.

Pain Catastrophizing: How Far Have We Come

The perception of pain is strongly influenced by various social, emotional, and cognitive factors. A psychological variable which has consistently been shown to exert its influence on pain is a cognitive process referred to as pain catastrophizing. Numerous studies have found it to be a strong predictor of pain intensity and disability across different clinical populations. It signifies a maladaptive response to pain marked by an exaggerated negative assessment, magnification of symptoms related to pain, and, in general, a tendency to experience marked pain-related worry, as well as experiencing feelings of helplessness when it comes to dealing with pain. Pain catastrophizing has been correlated to many adverse pain-related outcomes, including poor treatment response, unsatisfactory quality of life, and high disability related to both acute and chronic pain. Furthermore, there has been consistent evidence in support of a correlation between pain catastrophizing and mental health disorders, such as anxiety and depression. In this review, we aim to provide a comprehensive overview of the current state of knowledge regarding pain catastrophizing, with special emphasis on its clinical significance, and emerging treatment modalities which target it.

What do Finnish physiotherapists and physiotherapy students know about the neurophysiology of pain? The Finnish version of the revised Neurophysiology of Pain Questionnaire

BACKGROUND

Understanding the concept of pain and its underlying biological mechanisms is an essential part of physiotherapists' professional knowledge.

OBJECTIVES

The first aim of the study was to translate and cross-culturally adapt the revised Neurophysiology of Pain Questionnaire into Finnish (RNPQ-FI) and to evaluate its reliability (internal consistency and test-retest reliability) in a sample of Finnish physiotherapists and physiotherapy students. The second aim was to compare the knowledge of pain neurophysiology between these two groups.

METHODS

Translation and cross-cultural adaptation followed the COSMIN Study Design checklist. Participants (202 physiotherapists and 97 physiotherapy students) completed an online survey containing RNPQ-FI. Internal consistency was assessed with Cronbach's alpha and test-retest reliability using Intraclass correlation coefficient (ICC3,1).

RESULTS

Cronbach's alpha was 0.44 and ICC was 0.70 (p < .001). The mean percentage of correct responses was 61.4% for physiotherapists and 62.1% for students. Forty-seven percent of the physiotherapists and 35.1% of the students reported difficulties in understanding the items. A higher amount of pain education was associated with higher RNPQ-FI scores.

CONCLUSIONS

The RNPQ-FI showed low internal consistency and moderate test-retest reliability among Finnish physiotherapists and physiotherapy students. Physiotherapists and students had equal amount of pain neurophysiology knowledge. Pain education is encouraged.

Can a specific biobehavioral-based therapeutic education program lead to changes in pain perception and brain plasticity biomarkers in chronic pain patients? A study protocol for a randomized clinical trial

BACKGROUND

Chronic pain conditions are complex multifactorial disorders with physical, psychological, and environmental factors contributing to their onset and persistence. Among these conditions, the role of brain-derived neurotrophic factor (BDNF) and the impact of a specific therapeutic education (TE) on pain management have emerged as important areas of research.

OBJECTIVE

This study aims to investigate the effects of a specific type of therapeutic education on pain levels and BDNF concentrations.

METHODS

In this single-blind, randomized clinical trial, patients will be randomly assigned to one of two groups: one will receive exercise with TE and the other without TE. Assessments will be made at baseline, mid-treatment, post-intervention, and at one and eight months.

OUTCOMES

This study will shed light on the effectiveness of a therapeutic education (TE) program in pain management. Additionally, it will provide information on its effects on BDNF levels, a biomarker of brain plasticity, as well as on various psychosocial variables that can influence pain experience.

CONCLUSION

By comprehensively addressing the need to quantify brain changes more precisely in individuals with chronic pain during interventions like TE and recognizing the importance of establishing a more structured and comprehensive protocol, this study lays a solid and replicable foundation for future evidence-based treatment developments.

A systematic review of the added value of perioperative pain neuroscience education

OBJECTIVE

To identify and summarize evidence about the benefits of perioperative pain neuroscience education (PNE) on pain-related and psychosocial outcomes.

METHODS

Included were reports written in English that carried out PNE or its synonyms; perioperative period; aged ≥ 18 years; interventional studies and observational studies. Secondary studies, conference abstracts, and editorials were excluded. There was no time limitation.

INFORMATION SOURCES

PubMed, Virtual Health Library, Cochrane Library, and Science Direct. Search: June 20th 2023. The risk of bias was assessed using the Joanna Briggs Institute checklists, and synthesis followed the recommendations of the Synthesis Without Meta-analysis (SWiM) guideline. Register: Center for Open Science website (10.17605/OSF.IO/ZTNEJ).

RESULTS

The sample consisted of 18 reports. For pain outcomes, it was not possible to attribute PNE benefits because ten reports found improvements in both intervention and control groups. For psychosocial outcomes, fourteen reports found benefits for PNE groups. All the analyzed reports showed low risk of bias.

CONCLUSION

PNE had additional benefits beyond those obtained with conventional treatment for psychosocial outcomes.

PRACTICAL IMPLICATIONS

Due to the lack of evidence, it was not possible to indicate the clinical use of PNE. It is suggested that further studies are needed aimed at clarifying the possible benefits.

A scoping review of 'Pacing' for management of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): lessons learned for the long COVID pandemic

BACKGROUND

Controversy over treatment for people with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a barrier to appropriate treatment. Energy management or pacing is a prominent coping strategy for people with ME/CFS. Whilst a definitive definition of pacing is not unanimous within the literature or healthcare providers, it typically comprises regulating activity to avoid post exertional malaise (PEM), the worsening of symptoms after an activity. Until now, characteristics of pacing, and the effects on patients' symptoms had not been systematically reviewed. This is problematic as the most common approach to pacing, pacing prescription, and the pooled efficacy of pacing was unknown. Collating evidence may help advise those suffering with similar symptoms, including long COVID, as practitioners would be better informed on methodological approaches to adopt, pacing implementation, and expected outcomes.

OBJECTIVES

In this scoping review of the literature, we aggregated type of, and outcomes of, pacing in people with ME/CFS.

ELIGIBILITY CRITERIA

Original investigations concerning pacing were considered in participants with ME/CFS.

SOURCES OF EVIDENCE

Six electronic databases (PubMed, Scholar, ScienceDirect, Scopus, Web of Science and the Cochrane Central Register of Controlled Trials [CENTRAL]) were searched; and websites MEPedia, Action for ME, and ME Action were also searched for grey literature, to fully capture patient surveys not published in academic journals.

METHODS

A scoping review was conducted. Review selection and characterisation was performed by two independent reviewers using pretested forms.

RESULTS

Authors reviewed 177 titles and abstracts, resulting in 17 included studies: three randomised control trials (RCTs); one uncontrolled trial; one interventional case series; one retrospective observational study; two prospective observational studies; four cross-sectional observational studies; and five cross-sectional analytical studies. Studies included variable designs, durations, and outcome measures. In terms of pacing administration, studies used educational sessions and diaries for activity monitoring. Eleven studies reported benefits of pacing, four studies reported no effect, and two studies reported a detrimental effect in comparison to the control group.

CONCLUSIONS

Highly variable study designs and outcome measures, allied to poor to fair methodological quality resulted in heterogenous findings and highlights the requirement for more research examining pacing. Looking to the long COVID pandemic, our results suggest future studies should be RCTs utilising objectively quantified digitised pacing, over a longer duration of examination (i.e. longitudinal studies), using the core outcome set for patient reported outcome measures. Until these are completed, the literature base is insufficient to inform treatment practises for people with ME/CFS and long COVID.

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.

Dosage matters: Uncovering the optimal duration of pain neuroscience education to improve psychosocial variables in chronic musculoskeletal pain. A systematic review and meta-analysis with moderator analysis

The aim was to examine the moderator effect of duration of PNE (total minutes) on changes in psychosocial variables after treatment in people with chronic musculoskeletal pain. PubMed/MEDLINE, Embase, Web of Science, Scopus and CINHAL databases were systematically searched from inception to 6 February 2023. A mixed-effects meta-regression was performed to determine the moderator effect of PNE duration. Twenty-three studies involving 2352 patients were included. Meta-analysis revealed a statistically significant effect in favour of PNE on pain neurophysiology knowledge, anxiety symptoms, catastrophizing and kinesiophobia. The total duration of PNE ranged from 40 to 720 min. A linear relationship was observed between longer duration of PNE (total minutes) and changes of psychosocial variables. In addition, a dose of 100, 200 and 400 min of PNE was estimated to exceed the minimum clinically important difference described in the literature for kinesiophobia (mean difference = -8.53 points), anxiety symptoms (mean difference = -1.88 points) and catastrophizing (mean difference = -7.17 points). Clinicians should provide a more tailored PNE to address psychosocial variables.

Transcultural Adaptation and Psychometric Validation of the Spanish Version of the Pain Attitudes and Beliefs Scale for Physiotherapists

Low back pain (LBP) is one of the main musculoskeletal pain conditions, and it affects 23-28% of the global population. Strong evidence supports the absence of a direct relationship between the intensity of pain and tissue damage, with psychosocial factors also playing a crucial role. In this context, the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) is a useful tool for evaluating physiotherapists' treatment orientations and beliefs regarding the management of low back pain (LBP). It helps identify practitioners who may benefit from additional education in modern pain neuroscience. However, there is not a Spanish validation of this scale for physiotherapists. Thus, the aims of this study were to translate and culturally adapt the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) into Spanish and to evaluate its psychometric properties. This validation study used three convenience samples of physiotherapists (PTs) (n = 22 for the pilot study, n = 529 for the validity study and n = 53 for assessing the instrument's responsiveness). The process of translating and adapting the PABS-PT into Spanish followed international guidelines and produced a satisfactory pre-final version of the questionnaire. Factor analysis confirmed the two-factor structure of the original version, with the biomedical (BM) factor explaining 39.4% of the variance and the biopsychosocial (BPS) factor explaining 13.8% of the variance. Cronbach's alpha values were excellent for the BM factor (0.86) and good for the BPS factor (0.77), indicating good internal consistency. Test-retest reliability was excellent for both factors, with intraclass correlation coefficients (ICCs) of 0.84 for BM and 0.82 for BPS. The standard error of measurement (SEM) was acceptable for both factors (3.9 points for BM and 2.4 points for BPS). Concurrent validity was moderate and in the expected direction and had significant correlations with the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and Revised Neurophysiology Pain Questionnaire (R-NPQ). Sensitivity to change was demonstrated by significant improvements in both factors after an educational intervention, with medium-to-large effect sizes. The PABS-PT also showed good discriminative ability, as it was able to distinguish between physiotherapists with and without pain education. Cut-off values for the BM and BPS factors were determined. In conclusion, the translated and adapted Spanish version of the PABS-PT demonstrated good psychometric properties and can be reliably used to assess the attitudes and beliefs of Spanish-speaking physiotherapists regarding LBP. The questionnaire is recommended for use in clinical and educational research in the Spanish language context.

Expressed Beliefs about the Cause of Pain in a Pediatric Population: A Qualitative Study

(1) Background: The aims of this study are to explore what beliefs children and adolescents manifest about the cause of the pain they describe, to compare whether there are differences between beliefs by age and the persistence of pain, and to relate the explanations of the cause of pain with current scientific evidence. (2) Methods: a cross-sectional qualitative study was used. The primary endpoint of the study was obtaining explanations of the cause of pain recorded by means of an open-ended question. The participants were school-age children attending a charted school in the province of Barcelona. (3) Results: The children and adolescents proposed a diverse range of explanations for the cause of pain that they reported in their responses. The most frequent explanation for the cause of pain were pathologies and injuries (45.95%), ergonomic issues (22.60%) and psychological issues (15.95%). (4) Conclusions: There is a lot of variety in the explanations that young people give about the cause of their pain in schoolchildren aged between 10 and 16 years old. There exists a high prevalence of explanations non-associated with tissue damage (ENAD) concerning the causes of pain described. It is necessary that future health prevention programs dedicated to early ages consider which beliefs about the cause of pain are the most frequent in the pediatric population.

Pain Neuroscience Education in Elementary and Middle Schools

PURPOSE

The purpose of this study was to deliver pain neuroscience education (PNE) to participants in grades 3 to 8 to determine whether participants in these grades had positive shifts in pain knowledge and beliefs.

METHODS

Three hundred twenty participants, grades 3 to 8, received a 1-time, 30-minute PNE lecture. The Neurophysiology of Pain Questionnaire and the Health Care Provider's Pain and Impairment Relationship Scale were administered before and after the PNE lecture.

RESULTS

All grades improved in pain knowledge and beliefs. Higher-grade school participants (sixth to eighth grades) experienced larger shifts in pain knowledge and attitudes and beliefs than lower-grade (third to fifth grades) participants.

CONCLUSION

PNE results in changes in pain knowledge and beliefs in school participants in grades 3 to 8.

Effect of Pain Neuroscience Education with Conventional Physiotherapy via Telerehabilitation on Pain Catastrophizing and Function in Patients with Osteoarthritis Knee: A Randomized Controlled Trial

Aim

By explaining to the patient the biological processes underneath their pain condition, pain neuroscience education (PNE) is a form of educational intervention that aims to relieve pain and impairment.

Materials and Methods

Patients with knee osteoarthritis (OA) referred to outpatient physiotherapy clinic in India during August 2021 to June 2022 were asked to participate. Out of the eligible patients, 35 were randomly assigned to PNE group and 35 to the control group. Self-reports of Pain Catastrophizing Scale (PCS), Patient Specific Function Scale (PSFS), and Numerical Pain Rating Scale (NPRS) were recorded at baseline (T1) and at 2 weeks (T2).

Results

After 2 weeks of follow-up, all the three outcome measures were found to be significant in the PNE group. The results of the unpaired t-test revealed statistically significant result posttest for PCS (mean difference 11.4) and NPRS (mean difference 1.20). There was no mean difference found in the patient function (PSFS) between groups.

Conclusion

The results suggest that adding a program of PNE to conventional physiotherapy exercises led to a greater reduction in pain catastrophization, patient-specific function, and pain intensity rather than conventional physiotherapy alone in patients with knee OA at 2 weeks' follow-up.

Effectiveness of Pain Neuroscience Education in Patients with Chronic Musculoskeletal Pain and Central Sensitization: A Systematic Review

OBJECTIVE

To collect the available evidence about the effectiveness of pain neuroscience education (PNE) on pain, disability, and psychosocial factors in patients with chronic musculoskeletal (MSK) pain and central sensitization (CS).

METHODS

A systematic review was conducted. Searches were performed on Pubmed, PEDro, and CINAHL, and only randomized controlled trials (RCTs) enrolling patients ≥18 years of age with chronic MSK pain due to CS were included. No meta-analysis was conducted, and qualitative analysis was realized.

RESULTS

15 RCTs were included. Findings were divided for diagnostic criteria (fibromyalgia-FM, chronic fatigue syndrome-CFS, low back pain-LBP, chronic spinal pain-CSP). PNE has been proposed as a single intervention or associated with other approaches, and different measures were used for the main outcomes considered. Conclusions, practice implication: PNE is effective in improving pain, disability, and psychosocial factors in patients with fibromyalgia, chronic low back pain (CLBP)-especially if associated with other therapeutic approaches-and also in patients with CFS and CSP. Overall, PNE seems to be more effective when proposed in one-to-one oral sessions and associated with reinforcement elements. However, specific eligibility criteria for chronic MSK pain due to CS are still lacking in most RCTs; therefore, for future research, it is mandatory to specify such criteria in primary studies.

Non-Pharmacological Therapies for Post-Viral Syndromes, Including Long COVID: A Systematic Review

BACKGROUND

Post-viral syndromes (PVS), including Long COVID, are symptoms sustained from weeks to years following an acute viral infection. Non-pharmacological treatments for these symptoms are poorly understood. This review summarises the evidence for the effectiveness of non-pharmacological treatments for PVS.

METHODS

We conducted a systematic review to evaluate the effectiveness of non-pharmacological interventions for PVS, as compared to either standard care, alternative non-pharmacological therapy, or placebo. The outcomes of interest were changes in symptoms, exercise capacity, quality of life (including mental health and wellbeing), and work capability. We searched five databases (Embase, MEDLINE, PsycINFO, CINAHL, MedRxiv) for randomised controlled trials (RCTs) published between 1 January 2001 to 29 October 2021. The relevant outcome data were extracted, the study quality was appraised using the Cochrane risk-of-bias tool, and the findings were synthesised narratively.

FINDINGS

Overall, five studies of five different interventions (Pilates, music therapy, telerehabilitation, resistance exercise, neuromodulation) met the inclusion criteria. Aside from music-based intervention, all other selected interventions demonstrated some support in the management of PVS in some patients.

INTERPRETATION

In this study, we observed a lack of robust evidence evaluating the non-pharmacological treatments for PVS, including Long COVID. Considering the prevalence of prolonged symptoms following acute viral infections, there is an urgent need for clinical trials evaluating the effectiveness and cost-effectiveness of non-pharmacological treatments for patients with PVS.

REGISTRATION

The study protocol was registered with PROSPERO [CRD42021282074] in October 2021 and published in BMJ Open in 2022.

Education-Enhanced Conventional Care versus Conventional Care Alone for Temporomandibular Disorders: A Randomized Controlled Trial

The objective of this study was to determine the effect of enhancing conventional care for people with chronic painful temporomandibular disorders (TMD) with an individualised contemporary pain science education (PSE) intervention. In this randomized controlled trial, a consecutive sample of 148 participants (18-55 years of age) was randomized into 2 groups: PSE-enhanced conventional care or Conventional care alone. Conventional care involved a 6-week, 12-session manual therapy and exercise program. The PSE enhancement involved 2 sessions of modern PSE, undertaken in the first 2 treatment sessions. Primary outcomes were pain intensity, assessed with a numeric pain rating scale, and disability, assessed with the craniofacial pain and disability inventory, post-treatment. Linear mixed model analyses were used to investigate between-group differences over time. There was a statistically and clinically meaningful effect of PSE enhancement on disability (Mean Difference = 6.1, 95% CI: 3.3-8.8), but not on pain intensity, post-treatment. Secondary analyses suggested clinically meaningful benefit of PSE enhancement on pain and disability ratings at 10-week and 18-week follow-ups, raising the possibility that preceding conventional care with a PSE intervention may result in long-term benefits. PERSPECTIVE: The addition of modern Pain Science Education (PSE) intervention improved disability for people with chronic TMD receiving manual therapy and exercise, but not pain. A mean difference in pain and disability favoring the PSE group at the 10- and 18-week follow-ups, respectively, suggests that PSE addition resulted in longer-lasting effects. Trial registration: NCT03926767. Registered on April 29, 2019. https://clinicaltrials.gov/ct2/show/NCT03926767.

Targeting Pain Science Education in Youth With Chronic Pain: What Are the Sticking Points for Youth and Their Parents?

OBJECTIVES

An important part of providing pain science education is to first assess baseline knowledge and beliefs about pain, thereby identifying misconceptions and establishing individually-tailored learning objectives. The Concept of Pain Inventory (COPI) was developed to support this need. This study aimed to characterize the concept of pain in care-seeking youth and their parents, to examine its clinical and demographic correlates, and to identify conceptual gaps.

MATERIALS AND METHODS

Following an initial interdisciplinary evaluation, a cohort of 127 youth aged 8 to 18 years, and their parents, completed a series of questionnaires.

RESULTS

Parents had slightly higher COPI scores than youth did, reflecting parents' greater alignment with contemporary pain science. The moderate positive association with older age among youth ( r =.32) suggests that COPI is sensitive to cognitive development and life experiences. Youth and parent COPI responses were weakly associated ( r =0.24), highlighting the importance of targeting the concept of pain in both groups. For both parents and youth, 'Learning about pain can help you feel less pain' was the least endorsed concept. This conceptual 'gap' is a key point of intervention that could potentially lead to greater engagement with multidisciplinary pain treatment.

DISCUSSION

The COPI appears useful for identifying conceptual gaps or 'sticking points'; this may be an important step to pre-emptively address misconceptions about pain through pain science education. Future research should determine the utility of COPI in assessing and treating youth seeking care for pain. The COPI may be a useful tool for tailoring pain science education to youth and their parents.

Are Improvements in Pain Neurophysiology Knowledge Following Pain Science Education Associated With Improved Outcomes in People With Chronic Pain?: A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to determine the association between changes in patients' pain knowledge after pain science education (PSE) with treatment outcomes in people with chronic pain.

METHODS

Six electronic databases and 2 clinical trial registries were searched from inception to September 15, 2021 for studies where participants received PSE and had their pain knowledge and clinical outcomes assessed before and after PSE. Meta-analyses were performed for pain intensity, kinesiophobia, and pain catastrophizing. Physical function and quality of life outcomes were synthesized narratively. Risk of bias was assessed using the Cochrane tool for nonrandomized studies and the quality of evidence was assessed using GRADE.

RESULTS

Fourteen studies (n=1500 participants) were included. Meta-analyses revealed no significant associations between short-term (<12 wk) changes in pain neurophysiology knowledge with changes in pain intensity (n=1075, r=-0.01, 95% CI =-0.14 to 0.13, very low certainty), kinesiophobia (n=152, r=0.02, 95% CI =-0.27 to 0.24, very low certainty) and pain catastrophizing (n=976, r=-0.03, 95% CI=-0.18 to 0.11, low certainty). No significant associations were found between short-term changes in pain neurophysiology knowledge and physical function or quality of life either.

DISCUSSION

These findings do not support a short-term association between improvements in pain neurophysiology knowledge and better treatment outcomes in people with chronic pain. Increased understanding of how PSE works, as well as better ways to measure it, may help clinicians deliver more targeted education to help patients reconceptualize pain and promote engagement in active treatment strategies (eg, exercise).

"FastSchool": A single session of an interprofessional pain management program for chronic pain patients inspired by cognitive behavioral therapy

OBJECTIVES

Multidisciplinary approaches to treating chronic pain have been proven effective. Currently, chronic pain patients face lengthy waitlists in pain medicine departments. To overcome this problem, we developed the "FastSchool" program to educate patients about pain management and treatment. In this study, we evaluated the benefit of a "FastSchool" session on pain and catastrophizing in chronic pain patients.

METHODS

Included patients had chronic non-cancer pain, no more than 2 visits to a pain medicine department. Patients attended a single 3-hour session, conducted by an interprofessional team. Four topics were addressed: chronic pain mechanisms, pharmacological therapies, physical activity, and the management of analgesics. Patients completed questionnaires at baseline and at 3 months post-session to assess pain interference, pain intensity, and catastrophizing.

RESULTS

The study population included 88 patients; 71 completed the follow-up questionnaires. Pain interference (p = 0.002), average pain intensity (p = 0.013), and catastrophizing (p < 0.001) decreased 3 months after FastSchool. At M3, 35 % of patients felt their pain had improved based on the Patient Global Impression of Change.

CONCLUSION

FastSchool, an innovative short-term educational program inspired by cognitive behavioral therapy, showed positive results in reducing pain impact.

PRACTICE IMPLICATIONS

Implementation of FastSchool in pain medicine departments would reduce waitlist times for non-pharmacological treatment.

Non-invasive brain stimulation and pain neuroscience education in the cognitive-affective treatment of chronic low back pain: Evidence and future directions

Chronic low back pain (CLBP) is among the leading causes of disability worldwide. Beyond the physical and functional limitations, people's beliefs, cognitions, and perceptions of their pain can negatively influence their prognosis. Altered cognitive and affective behaviors, such as pain catastrophizing and kinesiophobia, are correlated with changes in the brain and share a dynamic and bidirectional relationship. Similarly, in the presence of persistent pain, attentional control mechanisms, which serve to organize relevant task information are impaired. These deficits demonstrate that pain may be a predominant focus of attentional resources, leaving limited reserve for other cognitively demanding tasks. Cognitive dysfunction may limit one's capacity to evaluate, interpret, and revise the maladaptive thoughts and behaviors associated with catastrophizing and fear. As such, interventions targeting the brain and resultant behaviors are compelling. Pain neuroscience education (PNE), a cognitive intervention used to reconceptualize a person's pain experiences, has been shown to reduce the effects of pain catastrophizing and kinesiophobia. However, cognitive deficits associated with chronic pain may impact the efficacy of such interventions. Non-invasive brain stimulation (NIBS), such as transcranial direct current stimulation (tDCS) or repetitive transcranial magnetic stimulation (rTMS) has been shown to be effective in the treatment of anxiety, depression, and pain. In addition, as with the treatment of most physical and psychological diagnoses, an active multimodal approach is considered to be optimal. Therefore, combining the neuromodulatory effects of NIBS with a cognitive intervention such as PNE could be promising. This review highlights the cognitive-affective deficits associated with CLBP while focusing on current evidence for cognition-based therapies and NIBS.

Using a discrete choice experiment to develop a decision aid tool to inform the management of persistent pain in pharmacy: a protocol for a randomised feasibility study

INTRODUCTION

In an era of personalised healthcare, it has become increasingly important to elicit individual-level preferences. While discrete choice experiments (DCEs) are widely used to measure patient preferences in the delivery of healthcare, the focus has been sample-level analysis. Using the DCE methodology, this project has designed a digital decision aid tool (DAT) with the potential to estimate individual preferences in real time to inform clinical consultation decisions in persistent pain management.

METHODS

Using a feasibility randomised control trial, this study aims to assess the feasibility of using this Understanding Persistent Pain (UPP) DAT in a pharmacy-based clinical setting and to test processes for a future definite randomised trial. Community and practice-based pharmacists (up to 10) will be recruited in The National Health Service (NHS) Grampian and trained in the use of the digital UPP DAT. Pharmacists will recruit up to 60 patients who are living with persistent pain. Patients will be randomised to one of two groups: using the UPP DAT or usual care. Pharmacists will follow-up patients as needed according to clinical need and following standard practice. DCE response data collected by the UPP DAT will be analysed using the penalised logit model, allowing estimation of individual preferences in real time. We will follow-up pharmacists and patients who use the UPP DAT to gather feedback on their experiences.

ETHICS AND DISSEMINATION

This study received ethical approval from the North of Scotland Research Ethics Committee (21/NS/0059) and received Research & Development Management Permission to proceed from NHS Grampian (2021UA003E). The study has been registered in the ClinicalTrials.gov database. Findings will be disseminated in peer-reviewed publications, presentations and newsletters and made available in the University of Aberdeen and Pharmacy Research UK websites. Participants gave informed consent to participate in the study before taking part.

TRIAL REGISTRATION NUMBER

NCT05102578; clinicaltrials.gov.

Evaluating the effectiveness of a comprehensive education on low back pain treatment outcomes: A controlled clinical study

OBJECTIVES

To investigate the effect of integrating an individualized, evidence-based low back pain comprehensive education package on low back pain treatment outcomes.

DESIGN

Single-blind, controlled clinical study using the alternate allocation of patients.

SETTING

Outpatient clinic.

SUBJECTS

In total, 54 participants with chronic low back pain (46.75 ± 11.11 years, 80% females) were randomized to intervention (n = 27) or a control group (n = 27).

INTERVENTION

The intervention group received additional four one-hour low back pain-related education sessions to eight 45 minutesstandard physical therapy sessions over 4 weeks.

OUTCOME MEASURES

Assessed at baseline, post-intervention, and 3 months. Outcome measures included pain intensity (Visual Analogue Scale), knowledge (Low Back Pain Knowledge Questionnaire), attitude (the Back Pain Attitudes Questionnaire), disability (the Oswestry Disability Index), mental health symptoms (Depression Anxiety Stress Scale, DASS-21 scale), and fear-avoidance (Fear-Avoidance Beliefs Questionnaire).

RESULTS

The intervention group showed significantly lower pain intensity ((4 weeks (3.58 ± 1.50 vs. 5.54 ± 1.92), 3 months (3.21 ± 1.74 vs. 5.69 ± 2.51)), higher knowledge ((4 weeks (21.67 ± 2.12 vs. 11.62 ± 3.47), three months (22.08 ± 3.40 vs. 12.23 ± 3.24)), lower negative attitudes ((4 weeks (99.29 ± 11.02 vs. 134.31 ± 12.97), 3 months (102.92 ± 15.58 vs. 132.42 ± 17.79)), lower disability ((4 weeks (26.30 ± 11.37 vs. 45.14 ± 18.67), 3 months (22.83 ± 16.06 vs. 44.13 ± 15.02)), lower stress score ((4 weeks (3.54 ± 3.01 vs. 8.81 ± 5.19), 3 months (3.21 ± 3.22 vs. 7.21 ± 4.36)), lower anxiety ((4 weeks (2.63 ± 3.16 vs. 6.42 ± 4.75), three months (2.63 ± 3.80 vs. 5.73 ± 4.44)), lower depression ((4 weeks (2.42 ± 2.15 vs. 6.42 ± 3.68), three months (2.63 ± 4.18 vs. 7.08 ± 4.41)), and lower fear-avoidance ((4 weeks (13.88 ± 12.32 vs. 50.88 ± 23.25), three months (15.50 ± 16.75 vs. 54.65 ± 31.81)).

CONCLUSION

Integrating low back pain comprehensive education into standard physical therapy might optimize the treatment outcomes of low back pain.

Improving functioning in HIV+ patients with chronic pain and comorbid depression: Protocol for a randomized clinical trial testing a collaborative behavioral health intervention based on behavioral activation

OBJECTIVE

Persons living with HIV (PWH) experience a disproportionate level of comorbid chronic pain and depression compared to individuals who do not have a diagnosis of HIV. Many PWH report pain that impairs daily function, is severe, and requires medical management. Depression alone is associated with HIV disease progression, medication non-adherence, and increased mortality. Given that numerous studies show that PWHs have chronic pain and depression despite pharmacologic treatment, there is a clear need for additional treatment modalities to address these conditions.

DESIGN

In this paper, we describe our protocol for a multisite, randomized controlled trial of the effectiveness of a collaborative behavioral intervention, called HIV-Pain and Sadness Support (HIVPASS), designed for PWH who endorse chronic pain and depressive symptoms, as compared to an attention matched Health Education (HE) condition. The HIVPASS intervention is based on Behavioral Activation and designed to target both pain and depression using an integrated model that promotes collaboration between HIV medical and psychological providers.

SETTING AND METHODS

We plan to (1) recruit PWH who endorse chronic pain and depression in three sites located in New England and the Midwestern United States and (2) compare our HIVPASS intervention to a full attention matched HE intervention with the primary outcome of pain interference, and secondary outcomes of depression, physical activity, HIV medication adherence, and health-related quality of life. Follow-up assessments will occur monthly for three months during the intervention phase and then during the post-intervention phase at months four, six, nine and twelve.

CONCLUSIONS

We provide descriptions of our protocol and interventions of our randomized controlled trial for comorbid chronic pain and depression in PWH.

TRIAL REGISTRATION

http://ClinicalTrials.govNCT02766751 https://clinicaltrials.gov/ct2/show/NCT02766751?term=stein%2C+michael&draw=2&rank=5.

Pain science education for children living with and beyond cancer: Challenges and research agenda

Pain in children living with and beyond cancer is understudied and undertreated. Pain science education (PSE) is a conceptual change strategy facilitating patients' understanding of the biopsychosocial aspects of pain. Preliminary studies on the adaptation of PSE interventions to adults with and beyond cancer provide a foundation for pediatric research. PSE could help childhood cancer survivors experiencing persistent pain and pain-related worry after active treatment. PSE may also help children receiving cancer treatment, providing them with a foundation of adaptive pain beliefs and cognitions, and preparing them for procedural and treatment-related pain. We direct this paper toward pediatric oncology clinicians, policy makers, and researchers working with children living with and beyond cancer. We aim to (a) identify challenges in adapting PSE for children living with and beyond cancer, (b) offer possible solutions, and (c) propose research questions to guide the implementation of PSE for children living with and beyond cancer.

A protocol for a randomized trial on pain neuroscience education vs. routine physical therapy in people with chronic neck pain

The aim of this study is to investigate the effects of combining routine physical therapy with pain neuroscience education (PNE) on psychosocial factors, physical performance, and the experienced pain in patients with chronic neck pain (CNP). This study is a double-blind randomized clinical trial in which patients will be randomly allocated to two groups, routine physical therapy with and without PNE. Patients will be assessed at the baseline, post intervention, and three months later. The results of this research will be used to establish effectiveness of treatment strategies for CNP. Due to the rigorous scientific methods used in this research, the suggested interventions would be clinically applicable in the health care systems.

The Effect of a Pain Educational Video Upon Child Pain-Related Memory and the Moderating Role of Parental Pain- and Non-Pain-Attending Verbalizations: An Experimental Lab-Based Study

OBJECTIVES

Early memories of pain contribute to fear and may underlie the maintenance and development of chronic pain into adulthood. Accordingly, understanding determinants that may impact children's pain memory development is key. This study examined (a) the effect of a brief engaging pain educational video in healthy children before undergoing an experimental pain task upon children's recalled pain intensity and pain-related fear and (b) the moderating role of parental pain- and non-pain-attending verbalizations before and after the pain task.

METHODS

Seventy-seven children (8-15 years old) participated in an experimental heat pain task, including actual heat pain stimuli delivered through a thermode on their forearm. Children were randomized to the experimental group (i.e., watching a pain educational video) or the control group (i.e., no video). Children's recalled pain intensity and pain-related fear were elicited 2 weeks later.

RESULTS

Findings showed that recalled pain intensity (but not recalled pain-related fear) of children who watched the pain educational video was significantly lower compared to the control group (p = .028). Further, parental pain-attending verbalizations before the pain task moderated the impact of the video upon children's recalled pain intensity (p = .038). Specifically, children in the control group, but not the experimental group, whose parents used less pain-attending verbalizations recalled higher pain intensity, whereas children whose parents used more pain-attending verbalizations recalled lower pain intensity.

CONCLUSIONS

As children's pain memories have important implications for pain assessment, treatment, and health across the lifespan, these findings might have important implications for the prevention of development or maintenance of maladaptive pain-related outcomes.

Effectiveness of training physical therapists in pain neuroscience education for patients with chronic spine pain: a cluster-randomized trial

ABSTRACT

Chronic spinal pain poses complex challenges for health care around the world and is in need of effective interventions. Pain neuroscience education (PNE) is a promising intervention hypothesized to improve pain and disability by changing individuals' beliefs, perceptions, and expectations about pain. Pain neuroscience education has shown promise in small, controlled trials when implemented in tightly controlled situations. Exploration of promising interventions through more pragmatic methodologies is a crucial but understudied step towards improving outcomes in routine clinical care. The purpose was to examine the impact of pragmatic PNE training on clinical outcomes in patients with chronic spine pain. The cluster-randomized clinical trial took place in 45 outpatient physical therapist (PT) clinics. Participants included 108 physical therapists (45 clinics and 16 clusters) and 319 patients. Clusters of PT clinics were randomly assigned to either receive training in PNE or no intervention and continue with usual care (UC). We found no significant differences between groups for our primary outcome at 12 weeks, Patient-Reported Outcomes Measurement Information System Physical Function computer adaptive test {mean difference = 1.05 (95% confidence interval [CI]: -0.73 to 2.83), P = 0.25}. The PNE group demonstrated significant greater improvements in pain self-efficacy at 12 and 2 weeks compared with no intervention (mean difference = 3.65 [95% CI: 0.00-7.29], P = 0.049 and = 3.08 [95% CI: 0.07 to -6.09], P = 0.045, respectively). However, a similar percentage of participants in both control (41.1%) and treatment (44.4%) groups reported having received the treatment per fidelity question (yes or no to pain discussed as a perceived threat) at 2 weeks. Pragmatic PT PNE training and delivery failed to produce significant functional changes in patients with chronic spinal pain but did produce significant improvement in pain self-efficacy over UC PT.

Amigos de Fibro (Fibro Friends): Validation of an Educational Program to Promote Health in Fibromyalgia

Health education is one of the main items to enable the promotion of health for individuals with fibromyalgia (FM) in Primary Health Care (PHC) in Brazil. The purpose of this study was to validate a multidisciplinary educational health promotion program called Amigos de Fibro (Fibro Friends) for individuals with FM. Methodological research involving 23 health professionals (expert judges) and 45 individuals with FM (target audience) used an instrument to assess the objectives, proposed themes and initiatives, relevance, writing style, and structure of the program through the Delphi technique. The content validity index (CVI) ≥ 0.78 and coefficient kappa ≥ 0.61 were used for data analysis. All 25 items evaluated in both groups presented considerable minimum CVI by CVI and the kappa coefficient. In the global evaluation of Amigos de Fibro, the CVI of the specialist judges was 0.90, while the values of the target audience judges were 0.95. The kappa coefficient of the expert judges was 0.90 and that of the target audience judges was 0.85. Amigos de Fibro, a light technology in health, was considered with adequate content validity and internal consistency and is, therefore, valid in the use by health professionals with the target audience in PHC, making it possible for them to act as health-promoting agents.

The impact of pain neuroscience education in a Hispanic-American population: A mixed-methods exploratory study

BACKGROUND

Chronic pain and pain catastrophization are growing problems across the United States, within the Hispanic-American population. Pain neuroscience education (PNE) changes pain knowledge and beliefs in many populations, but its impact on reconceptualization in people of Hispanic-American origin is unknown.

PURPOSE

Explore the changes in pain knowledge in Hispanic-American individuals and the process involved in reconceptualization following a PNE lecture.

METHODS

Eight Hispanic-American adults participated in a mixed-methods exploratory study. The Revised Neurophysiology of Pain Questionnaire (R-NPQ) was completed before, immediately after, and eight months after an adapted PNE lecture. A focus group involving four participants discussed the impact of PNE. Transcripts were translated and theme coded, and a concept map was developed by consensus.

RESULTS

R-NPQ scores improved from 25.3% to 43.5% post-lecture, and the number of unsure responses decreased from 41.5% to 18.4%. At eight months, R-NPQ scores remained stable (44.2%) but unsure responses increased (28.9%). Themes that contributed to the process of change included cognitive dissonance, relevance of instruction, idea exchange through peer interaction, reflection, confidence, changed behaviors, and educational utility.

CONCLUSION

While small improvements in knowledge and perception of pain appeared to occur with the PNE, knowledge remained low. Consideration of adult learning principles such as applicability, peer-interaction, the confrontation of beliefs, and reflection throughout PNE may enhance its impact. Future investigation should explore the efficacy of this intervention, when compared or combined with other techniques in the treatment of Hispanic-Americans experiencing persistent pain.

Comparison the Effect of Pain Neuroscience and Pain Biomechanics Education on Neck Pain and Fear of Movement in Patients with Chronic Nonspecific Neck Pain During the COVID-19 Pandemic

Introduction

Self-management education is the basis of any intervention for persons with chronic musculoskeletal pain. Given the biopsychosocial nature of chronic musculoskeletal pain, an educational approach based on the biopsychosocial model would seem to be an appropriate educational model for the treatment of these people during coronavirus disease 2019 (COVID-19). The aim of this study was to compare the effect of pain neuroscience education (PNE) and pain biomechanics education, using online and face-to-face sessions on pain and fear of movement, in people with chronic nonspecific neck pain during COVID-19.

Methods

In this multicenter assessor-blinded randomized controlled trial, 80 patients (both male and female) with chronic nonspecific neck pain (based on the inclusion criteria of the study) participated in educational sessions (face-to-face and online) from the beginning September until the end of October 2021. The participants were randomly divided into two groups (through the selection of numbers from 1 to 80, hidden in a box), with one group receiving PNE (treatment group) and the other group receiving pain biomechanics education (control group). Pain and fear of movement before and after the intervention were measured on the Numerical Pain Rating Scale and the Tampa Scale of Kinesiophobia, respectively. A 2 × 2 variance analysis (treatment group × time) with a mixed-model design was applied to statistically analyze the data.

Results

No significant change in pain (P = 0.23) was observed between the two groups (P = 0.24, Cohen's d = 0.17, 95% confidence interval [CI] − 0.21 to 0.35), while changes in the fear of movement variable were reported to be significant (P = 0.04, Cohen's d = 0.34, 95% CI 0.11–0.51), in favor of PNE. Intra-group change was seen only in the PNE group for the fear of movement variable (P = 0.04; 14.28%↓).

Conclusion

In our study population PNE did not affect the pain index, leading to the conclusion that PNE should not be used as the only treatment, but possibly in combination with other active/passive therapy to enhance the results for patients with nonspecific chronic neck pain. Moreover, online treatment may help clinicians to increase their interaction with patients during COVID-19 lockdown.

Network Analysis of Symptoms Co-Occurrence in Chronic Fatigue Syndrome

Chronic fatigue syndrome (CFS) is a heterogenous disorder of multiple disabling symptoms with complex manifestations. Network analysis is a statistical and interrogative methodology to investigate the prevalence of symptoms (nodes) and their inter-dependent (inter-nodal) relationships. In the present study, we explored the co-occurrence of symptoms in a cohort of Polish CFS patients using network analysis. A total of 110 patients with CFS were examined (75 females). The mean age of the total sample was 37.93 (8.5) years old while the mean duration of symptoms in years was 4.4 (4). Post-exertional malaise (PEM) was present in 75.45% of patients, unrefreshing sleep was noted in 89.09% and impaired memory or concentration was observed in 87.27% of patients. The least prevalent symptom was tender cervical or axillary lymph nodes, noted in 34.55% of the total sample. Three of the most densely connected nodes were the total number of symptoms, sore throat and PEM. PEM was positively related with impairment in memory or concentration. Both PEM and impairment in memory or concentration presence are related to more severe fatigue measured by CFQ and FIS. PEM presence was positively related with the presence of multi-joint pain and negatively with tender lymph nodes and muscle pain. Sore throat was related with objective and subjective autonomic nervous system impairment. This study helps define symptom presentation of CFS with the pathophysiology of specific systems and links with multidisciplinary contemporary molecular pathology, including comparative MRI.

The Concept of Pain Inventory for Adults (COPI-Adult): Assessing Knowledge and Beliefs Regarding Pain Science Education

OBJECTIVES

Assessing knowledge and beliefs regarding pain science can identify gaps and misconceptions. The Concept of Pain Inventory (COPI) was recently developed in children with the intent to guide targeted pain science education. We utilized the original COPI item pool to (1) develop a tool to assess an adult's concept of pain in a cohort who had not received pain science education, (2) evaluate its psychometric properties, (3) examine distribution of scores in a cohort of adults who had received pain science education, and (4) examine associations between scores and clinical variables.

MATERIALS AND METHODS

A total cohort of 627 adults were recruited through social media for an online survey. Initial development was conducted on those who had not received prior pain science education (n=125), then the COPI-Adult tool was tested in those who had received prior pain science education (n=502).

RESULTS

The resulting unidimensional 13-item COPI-Adult had acceptable internal consistency (α=0.78) and good test-retest reliability at 1 week (Intraclass Correlation Coefficient3,1=0.84 (95% confidence interval: 0.71-0.91). Higher COPI-Adult scores reflect greater alignment with contemporary pain science. COPI-Adult scores were correlated with revised Neurophysiology of Pain Questionnaire (rNPQ) scores and inversely correlated with average and current pain intensity, and pain interference. Adults who reported having received pain science education had significantly higher mean COPI-Adult scores than those who had not, and this difference exceeded the smallest detectable change.

DISCUSSION

The COPI-Adult is a brief questionnaire with promising psychometric properties to identify conceptual gaps or misconceptions to inform individualized pain science education.

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.

Pain neuroscience education combined with usual treatment for fibromyalgia syndrome: A randomized controlled trial

AIM

The aim of this study was to investigate the effectiveness of pain neuroscience education (PNE) in addition to usual treatment in patients with fibromyalgia syndrome.

METHODS

Forty patients were randomized into 2 groups. The experimental group underwent PNE sessions over 6 weeks in addition to pharmacological treatment, and the control group was given only pharmacological treatment. The primary outcome measure was functional status and the secondary outcome measures were widespread pain pressure threshold and kinesiophobia level. All assessments were conducted before the intervention and at the end of the 6th and 12th weeks by the same blinded researcher.

RESULTS

The intervention group had significantly greater improvement than the control group in terms of the mean total scores in the Fibromyalgia Impact Questionnaire (P = .001) and the Tampa Scale of Kinesiophobia (P = .001) with large effect sizes. The intervention group also had significantly greater improvement in the pain pressure threshold values of the cervical (P = .040), thoracic (P = .001), lumbar (P < .001), elbow (P = .005) and calf (P = .006) regions with moderate-to-large effect sizes.

CONCLUSION

This study showed that the addition of 6-week PNE sessions to pharmacological treatment was successful in improving functional status, widespread pain pressure threshold, and level of kinesiophobia in patients with fibromyalgia syndrome during a 12-week follow-up period.

Current Understanding of Pain Neurophysiology among Physiotherapists Practicing in Saudi Arabia

To ensure the effective management of patients’ pain, it is important that physiotherapists have a good understanding of the neuroscience behind pain. A major barrier to adequate pain management is that, for patients, there is limited access to clinicians who are knowledgeable about pain. This study examined the level of knowledge regarding pain neurophysiology among physiotherapists currently practicing in Saudi Arabia. Method: The study was a cross-sectional web-based survey that utilized the 12-item Revised Neurophysiology of Pain Questionnaire. Descriptive and inferential statistics were used to describe levels of knowledge regarding pain neurophysiology and to examine differences in knowledge based on the characteristics of the participating physiotherapists (gender, educational level, experience, practice region, and country where their highest educational level was attained). Results: One hundred and eleven physiotherapists (58.6% male) from various regions and educational backgrounds participated in the study. Out of a maximum Revised Neurophysiology of Pain Questionnaire score of 12, the mean ± standard deviation (SD) was 6.7 ± 2.2; 90% of physiotherapists scored 9 (75%) or less. None of the examined characteristics of the participants were associated with knowledge. Conclusion: Physiotherapists in Saudi Arabia showed limited knowledge of the neurophysiology of pain; however, this was not related to the personal characteristics that were examined. The continuation of education in modern pain science is recommended for physiotherapists, especially those dealing with patients suffering from chronic pain. Clinical Relevance: The physiotherapists who took part in this study displayed limited knowledge of pain neuroscience; this limited knowledge might suggest the need for a more bio-anatomical approach to pain management. There is a need for tailored medical education to address pain neuroscience knowledge in current physiotherapist practitioners.

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.

Pain Neuroscience Education Delivered by a Student Physical Therapist for a Patient with Persistent Musculoskeletal Pain

BACKGROUND Persistent pain is one of the most common reasons individuals seek healthcare in the United States, costing $635 billion annually. At present, the medical literature outlines many treatments for persistent pain. Pain neuroscience education (PNE) is described in the literature as an educational intervention for patients with persistent pain that can be applied by a physical therapist. There is limited research on the application of PNE by a student physical therapist; however, this case report offers a unique opportunity to examine outcomes for this intervention when applied by a student physical therapist in conjunction with manual therapy and therapeutic exercise. CASE REPORT This case report examined the outcomes of PNE for a 65-year-old patient with a long-standing history of low back, cervical, shoulder, knee, and foot pain. Interventions included 7 sessions of PNE over 4 weeks delivered by a student physical therapist, in combination with manual therapy and exercise prescribed by a licensed physical therapist. Outcomes measured were fear avoidance belief questionnaire, visual analog scale, Tampa scale of kinesiophobia, neurophysiology of pain questionnaire, neck disability index, and Oswestry disability index. CONCLUSIONS Outcomes included clinically significant decreases in subjective pain level, and kinesiophobia; however, there was only a minimal decrease in fear avoidance and no decrease in perceived disability. This case report provides preliminary evidence that positive outcomes can be achieved when PNE is delivered by a student physical therapist combined with manual therapy and therapeutic exercise from an expert clinician for patients with persistent musculoskeletal pain.