Exercise-induced hypoalgesia after acute and regular exercise: experimental and clinical manifestations and possible mechanisms in individuals with and without pain

This review describes methodology used in the assessment of the manifestations of exercise-induced hypoalgesia in humans and previous findings in individuals with and without pain. Possible mechanisms and future directions are discussed.

Exercise and physical activity is recommended treatment for a wide range of chronic pain conditions. In addition to several well-documented effects on physical and mental health, 8 to 12 weeks of exercise therapy can induce clinically relevant reductions in pain. However, exercise can also induce hypoalgesia after as little as 1 session, which is commonly referred to as exercise-induced hypoalgesia (EIH). In this review, we give a brief introduction to the methodology used in the assessment of EIH in humans followed by an overview of the findings from previous experimental studies investigating the pain response after acute and regular exercise in pain-free individuals and in individuals with different chronic pain conditions. Finally, we discuss potential mechanisms underlying the change in pain after exercise in pain-free individuals and in individuals with different chronic pain conditions, and how this may have implications for clinical exercise prescription as well as for future studies on EIH.

The effect of graded activity and pain education (GAPE): an early post-surgical rehabilitation programme after lumbar spinal fusion-study protocol for a randomized controlled trial

Background

Patients with chronic low back pain undergoing lumbar spinal fusion (LSF) are physically inactive and thereby at risk of poor health. Barriers to being physically active need to be acknowledged in post-surgical rehabilitation. The primary objective of this randomized controlled trial (RCT) is to examine the effect of an early active intervention consisting of graded activity and pain education (GAPE) on sedentary behaviour in a population of patients undergoing LSF. The secondary objective is to examine the effect of GAPE on disability, pain, fear of movement, self-efficacy for exercise, and health-related quality of life.

Methods

The study is an RCT planned to include 144 patients undergoing LSF at 1–2 levels for low back pain caused by degeneration of the lumbar spine. The patients will be randomly assigned to receive either usual care or usual care plus GAPE. GAPE consists of nine individual physiotherapist-guided sessions over a 10-week period. The overall purpose is to reduce sedentary behaviour, by educating the patient about pain and, based on a cognitive behavioural perspective, gradually strengthen the patient’s self-efficacy to be physically active and reduce fear of movement. The physiotherapist will plan the intervention in collaboration with the patient. Based on a semi-structured interview and observations of the patient in their home, they will set individually functional goals. The primary outcome will be a reduction in sedentary behaviour, measured by an accelerometer at baseline (pre-surgery) and at 3 and 12 months post-surgery. Secondary outcomes will include disability, pain, fear of movement, self-efficacy for exercise, and quality of life. Secondary outcome data will be collected at baseline (pre-surgery) and at 3, 6 and 12 months post-surgery.

Discussion

We hypothesize that, compared with the “usual care group”, GAPE will primarily lead to a significant reduction in sedentary behaviour, and secondarily a reduction in disability, pain intensity, and fear of movement; further, it will increase the patient’s self-efficacy for exercise and quality of life.

Trial registration

www.clinicaltrials.gov NCT04103970, Registered on 24 September 2019

Effectiveness of communicative and educative strategies in chronic low back pain patients: A systematic review

OBJECTIVE

To investigate the effectiveness of communicative and educative strategies on 1) patient's low back pain awareness/knowledge, 2) maladaptive behavior modification and 3) compliance with exercise in patients with chronic low back pain.

METHODS

A systematic review was conducted. Searches were performed on 13 databases. Only randomized controlled trials enrolling patients ≥ 18 years of age were included. Risk of bias was assessed with the Cochrane Collaboration's tool and interrater agreement between authors for full-texts selection was evaluated with Cohen's Kappa. No meta-analysis was performed and qualitative analysis was conducted.

RESULTS

24 randomized controlled trials which intervention included communicative and educative strategies were selected. Most of the studies were judged as low risk of bias and Cohen's Kappa was excellent ( = 0.822). Interventions addressed were cognitive behavioral therapy as unique treatment or combined with other treatments (multimodal interventions), coaching, mindfulness, pain science education, self-management, graded activity and graded exposure.

CONCLUSIONS, PRACTICE IMPLICATION

Patient's low back pain awareness/knowledge is still a grey area of literature. Pain science education, graded exposure and multimodal interventions are the most effective for behavior modification and compliance with exercise with benefits also in the long-term, while self-management, graded activity and coaching provide only short-term or no benefits.

Meta-Analysis of Integrated Therapeutic Methods in Noninvasive Lower Back Pain Therapy (LBP): The Role of Interdisciplinary Functional Diagnostics

Introduction. Lower back pain (LBP) is almost a problem of civilizations. Quite often, it is a consequence of many years of disturbed distribution of tension within the human body caused by local conditions (injuries, hernias, stenoses, spondylolisthesis, cancer, etc.), global factors (postural defects, structural integration disorders, lifestyle, type of activity, etc.), or systemic diseases (connective tissue, inflammation, tumours, abdominal aneurysm, and kidney diseases, including urolithiasis, endometriosis, and prostatitis). Therefore, LBP rehabilitation requires the use of integrated therapeutic methods, combining the competences of interdisciplinary teams, both in the process of diagnosis and treatment. Aim of the Study. Given the above, the authors of the article conducted meta-analysis of the literature in terms of integrated therapeutic methods, indicating the techniques focused on a holistic approach to the patient. The aim of the article is to provide the reader with comprehensive knowledge about treating LBP using noninterventional methods. Material and Methods. An extensive search for the materials was conducted online using PubMed, the Cochrane database, and Embase. The most common noninterventional methods have been described, as well as the most relevantly updated and previously referenced treatment of LBP. The authors also proposed noninvasive (measurable) diagnostic procedures for the functional assessment of the musculoskeletal system, including initial, systematic, and cross-sectional control. All figures and images have been prepared by the authors and are their property.

Results

This review article goes beyond combining a detailed description of each procedure with full references, as well as a comprehensive discussion of this very complex and troublesome problem.

Conclusions

Lower back pain is a serious health problem, and this review article will help educate physicians and physiotherapists dealing with LBP in the options of evidence-based treatment. Ultimately, the article introduces and postulates the need to systematize therapeutic procedures in LBP therapy, with a long-term perspective.

Pain Education With Therapeutic Exercise in Chronic Nonspecific Low Back Pain Rehabilitation: A Critically Appraised Topic

Clinical Scenario: Low back pain is widely prevalent in the general population as well as in athletes. Therapeutic exercise is a low-risk and effective treatment option for chronic pain that can be utilized by all rehabilitation clinicians. However, therapeutic exercise alone does not address the psychosocial aspects that are associated with chronic low back pain. Pain education is the umbrella term utilized to encompass any type of education to the patient about their chronic pain. Therapeutic exercise in combination with pain education may allow for more well-rounded and effective treatment for patients with chronic nonspecific low back pain (NS-LBP). Clinical Question: Does pain education combined with therapeutic exercise, compared with therapeutic exercise alone, improve patient pain in adults with chronic NS-LBP over a 2- to 3-month treatment period? Summary of Key Findings: A thorough literature review yielded 8 studies potentially relevant to the clinical question, and 3 studies that met the inclusion criteria were included. The 3 studies included reports that exercise therapy reduced symptoms. Two of the 3 included studies support the claim that exercise therapy reduces the symptoms of chronic NS-LBP when combined with pain education, whereas one study found no difference between pain education with therapeutic exercise. Clinical Bottom Line: There is moderate evidence to support the use of pain education along with therapeutic exercise when attempting to reduce symptoms of pain and disability in patients with chronic NS-LBP. Educational interventions should be created to educate patients about the foundation of pain, and pain education should be implemented as a part of the clinician's strategy for the rehabilitation of patients with chronic NS-LBP. Strength of Recommendation: Grade B evidence exists to support the use of patient education with therapeutic exercise for decreasing pain in patients with chronic NS-LBP.

Pain-related psychological issues in hand therapy

STUDY DESIGN

Literature review.

INTRODUCTION

Pain is a subjective experience that results from the modulation of nociception conveyed to the brain via the nervous system. Perception of pain takes place when potential or actual noxious stimuli are appraised as threats of injury. This appraisal is influenced by one's cognitions and emotions based on her/his pain-related experiences, which are processed in the forebrain and limbic areas of the brain. Unarguably, patients' psychological factors such as cognitions (eg, pain catastrophizing), emotions (eg, depression), and pain-related behaviors (eg, avoidance) can influence perceived pain intensity, disability, and treatment outcomes. Therefore, hand therapists should address the patient pain experience using a biopsychosocial approach. However, in hand therapy, a biomedical perspective predominates in pain management by focusing solely on tissue healing.

PURPOSE OF THE STUDY

This review aims to raise awareness among hand therapists of the impact of pain-related psychological factors.

METHODS AND RESULTS

This literature review allowed to describe (1) how the neurophysiological mechanisms of pain can be influenced by various psychological factors, (2) several evidence-based interventions that can be integrated into hand therapy to address these psychological issues, and (3) some approaches of psychotherapy for patients with maladaptive pain experiences.

DISCUSSION AND CONCLUSION

Restoration of sensory and motor functions as well as alleviating pain is at the core of hand therapy. Numerous psychological factors including patients' beliefs, cognitions, and emotions alter their pain experience and may impact on their outcomes. Decoding the biopsychosocial components of the patients' pain is thus essential for hand therapists.

Neurophysiological Pain Education for Patients With Chronic Low Back Pain: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the effect of neurophysiological pain education (NPE) for patients with chronic low back pain (CLBP).

METHODS

A systematic search was performed in 6 electronic databases. Eligible randomized-controlled trials were those with at least 50 % of patients with CLBP and in which NPE was compared with no intervention or usual care. Methodological quality was assessed independently by 2 of the authors using the Cochrane Collaboration Risk of Bias Tool. The effect of NPE was summarized in a random effect meta-analysis for pain, disability, and behavioral attitudes. Effect was estimated as weighted mean difference (WMD) if outcomes were on the same scale or as standardized mean difference (SMD). The overall quality of evidence was evaluated according to GRADE guidelines.

RESULTS

Seven randomized-controlled trial studies (6 low and 1 high quality) were included. Statistically significant differences in pain, in favor of NPE, were found after treatment, WMD=-1.03 (95% confidence interval [CI], -0.55 to -1.52), and after 3 months, WMD=-1.09 (95% CI, -2.17 to 0.00). Furthermore statistically significant lower disability was found in the NPE group after treatment, SMD=-0.47 (95% CI, -0.80 to -0.13) and after 3 months SMD=-0.38 (95% CI, -0.74 to -0.02). The difference in favor of NPE in reduction in Tampa Scale of Kinesiophobia was not statistically significant, WMD=-5.73 (95% CI, -13.60 to 2.14) and after 3 months WMD=-0.94 (95% CI, -6.28 to 4.40).

DISCUSSION

There was moderate evidence supporting the hypothesis that NPE has a small to moderate effect on pain and low evidence of a small to moderate effect on disability immediately after the intervention. NPE has a small to moderate effect on pain and disability at 3 months follow-up in patients with CLBP.

Multi-disciplinary interventions for chronic pain involving education: A systematic review

BACKGROUND

There have been growing recommendations to include education in multi-disciplinary interventions targeting chronic pain management. However, effects of this strategy on short- and long-term self-management of chronic pain, remain largely unexplored.

OBJECTIVES

1. To provide an updated overview of studies that report on the impact of patient education in multi-disciplinary interventions, on self-management of chronic pain; 2. To explore associations between education and chronic pain self-management techniques; and 3. To identify the format and duration of suitable chronic pain interventions targeted at patient self-management.

METHODS

Design: Narrative systematic literature review of randomised or controlled study designs. Data Sources: PubMed, CINAHL, EMBASE, PsycINFO. Participants: Adult patients with chronic pain of any aetiology participating in multi-disciplinary programs that included education. Main outcome measures: Assessments of level of pain, function, quality of life, self-efficacy, self-management, and any other relevant assessments. Study Appraisal and Synthesis Methods: PRISMA guidelines, Cochrane Risk of Bias tool, and TIDieR model.

RESULTS

Database searching identified 485 potential papers. After removal of duplicates, and irrelevant articles by title and abstract, 120 full-text articles were reviewed and 27 studies were included in this systematic review. Studies were predominantly from the United States (n = 8; 29.6%). Over one hundred outcome measures were identified across all studies, with significant variation also observed in terms of how chronic pain duration was defined, and how education was delivered to participants. Overall, positive benefits of education were reported.

CONCLUSIONS

Education, as part of multi-disciplinary programs, is likely to improve self-management and self-efficacy in people with chronic pain of any aetiology. Heterogeneity in terms of: chronic pain duration; educational resources; healthcare professionals; and outcome measures, were identified as limitations. Further research, in the form of Randomised Controlled Trials addressing these limitations, is recommended.

Conservative Interventions Reduce Fear in Individuals With Chronic Low Back Pain: A Systematic Review

OBJECTIVE

To systematically review and critically appraise the effectiveness of conservative and surgical interventions to reduce fear in studies of people with chronic low back pain, based on the analysis of randomized controlled trials for which fear was a primary or secondary outcome.

DATA SOURCES

Electronic databases PubMed, CINAHL, PsycINFO, PEDro, and CENTRAL, as well as manual searches and grey literature were searched from inception until May 2019.

STUDY SELECTION

Randomized controlled trials analyzing the effectiveness of conservative and surgical interventions to reduce fear were included.

DATA EXTRACTION

Two reviewers independently conducted the search strategy, study selection, data extraction, risk of bias assessment, and quality of the evidence judgment.

DATA SYNTHESIS

Sixty-one studies (n=7201) were included. A large number of fear-related search terms were used but only 3 fear constructs (kinesiophobia, fear-avoidance beliefs, fear of falling) were measured in the included studies. Multidisciplinary and psychological interventions as well as exercise reduced kinesiophobia. Fear-avoidance beliefs were reduced by the aforementioned interventions, manual therapy, and electrotherapy. A multidisciplinary intervention reduced the fear of falling. There was moderate evidence of multidisciplinary interventions and exercise to reduce kinesiophobia. There was moderate evidence of manual therapy and electrotherapy to reduce fear-avoidance beliefs.

CONCLUSIONS

The present systematic review highlights the potential effectiveness of conservative interventions to reduce kinesiophobia and fear-avoidance beliefs in individuals with chronic low back pain. This information can help health professionals to reduce fear when treating patients with this condition.

Physical rehabilitation therapists' perspective of the opioid crisis with evidence-based recommendations

In 2017, the Secretary of Health and Human Services and Office of the Surgeon General declared the opioid crisis of our nation to be a public health emergency. In response to the Office of the Assistant Secretary of Health and Office of the Surgeon General's 'Call to Action', the Therapist category of the US Public Health Service commissioned a nine-member task force consisting of pain science subject matter experts to study the Therapists' role in effectively reducing chronic pain and opioid abuse. This article addresses the opioid epidemic, how patients with chronic pain have been managed inappropriately, and five key, evidence-based recommendations from this task force.

The impact of combining pain education strategies with physical therapy interventions for patients with chronic pain: A systematic review and meta-analysis of randomized controlled trials

Study Design: Systematic Review with meta-analysis.Background: Rehabilitation providers have begun to incorporate pain education into their treatment protocols to influence the patient's experience and knowledge to improve their condition. The purpose of this systematic review is to determine if the addition of pain education strategies to physical therapy treatments is beneficial in reducing pain intensity and disability for those with chronic musculoskeletal pain.Methods: A systematic database search was conducted for randomized control trials that investigated the concurrent use of pain education and physical therapy. Standardized methods for article identification, inclusion, and quality appraisal was utilized. Where possible, studies were pooled for meta-analysis, with pain and disability as the primary outcomes.Results: Fourteen articles were included in this review, of which all fourteen were rated as high quality using the PEDro scale of quality assessment. Meta-analyses were conducted on pain and disability constructs at short term (< 12 weeks) and long-term (≥ 12 weeks) for the studies that allowed for quantitative pooling of effect sizes. Thirteen out of the fourteen included studies demonstrated a decrease in pain and disability with the use of combined interventions. There was a large effect on short-term pain (SMD 0.837), long-term pain (SMD 0.964), and long-term disability (SMD 1.374). A moderate effect on with short-term disability (SMD 0.791).Conclusion: The results of this systematic review support the conclusion that utilizing pain education strategies in conjunction with interventions provided by physical therapists demonstrates a moderate to large effect sizes on pain and disability constructs but lack pooled statistical significance.

Effects of whole-body vibration exercise for non-specific chronic low back pain: an assessor-blind, randomized controlled trial

OBJECTIVE

To confirm the benefits of whole-body vibration exercise for pain intensity and functional disability in patients with non-specific chronic low back pain.

DESIGN

Single-blind randomized controlled trial.

SETTING

Outpatient.

SUBJECTS

Eighty-nine patients with non-specific chronic low back pain met the inclusion criteria, they were randomly allocated to either the intervention group (n = 45) or the control group (n = 44).

INTERVENTION

The intervention group received whole-body vibration exercises three times a week for 12 weeks. The control group received general exercise protocol three times a week for 12 weeks.

MAIN OUTCOMES

The primary outcome measures were pain intensity and functional disability measured by the visual analog scale scores and Oswestry Disability Index. The secondary outcome measures included lumbar joint position sense, quality of life (Short Form Health Survey 36) and overall treatment effect (Global Perceived Effect).

RESULTS

A total of 84 subjects completed the 12-week study program. After 12 weeks, compared with the control group, the mean visual analog scale and Oswestry Disability Index scores decreased by additional 1 point (95% confidence interval (CI) = -1.22 to -0.78; P < 0.001), 3.81 point (95% CI, -4.98, -2.63; P < 0.001) based on adjusted analysis in the intervention group. And the intervention group provided additional beneficial effects for in terms of lumbar joint position sense (P < 0.05), quality of life (P < 0.05), and Global Perceived Effect (P = 0.012).

CONCLUSION

The study demonstrated that whole-body vibration exercise could provide more benefits than general exercise for relieving pain and improving functional disability in patients with non-specific chronic low back pain.

Pain Neuroscience Education for Adults With Chronic Musculoskeletal Pain: A Mixed-Methods Systematic Review and Meta-Analysis

Chronic musculoskeletal pain (CMP) is an urgent global public health concern. Pain neuroscience education (PNE) is an intervention used in the management of CMP aiming to reconceptualize an individual's understanding of their pain as less threatening. This mixed-methods review undertook a segregated synthesis of quantitative and qualitative studies to investigate the clinical effectiveness, and patients' experience of, PNE for people with CMP. Electronic databases were searched for studies published between January 1, 2002, and June 14, 2018. Twelve randomized, controlled trials (n = 755 participants) that reported pain, disability, and psychosocial outcomes and 4 qualitative studies (n = 50 participants) that explored patients experience of PNE were included. The meta-analyzed pooled treatment effects for PNE versus control had low clinical relevance in the short term for pain (-5.91/100; 95% confidence interval [CI], -13.75 to 1.93) and disability (-4.09/100; 95% CI, -7.72 to -.45) and in the medium term for pain (-6.27/100; 95% CI, -18.97 to 6.44) and disability (-8.14/100; 95% CI, -15.60 to -.68). The treatment effect of PNE for kinesiophobia was clinically relevant in the short term (-13.55/100; 95% CI, -25.89 to -1.21) and for pain catastrophizing in the medium term (-5.26/52; 95% CI, -10.59 to .08). A metasynthesis of 23 qualitative findings resulted in the identification of 2 synthesized findings that identified several key components important for enhancing the patient experience of PNE, such as allowing the patient to tell their own story. These components can enhance pain reconceptualization, which seems to be an important process to facilitate patients' ability to cope with their condition. The protocol was published on PROSPERO (CRD42017068436). Perspective: We outline the effectiveness of PNE for the management of pain, disability, and psychosocial outcomes in adults with CMP. Key components that can enhance the patient experience of PNE, such as allowing the patient to tell their own story, are also presented. These components may enhance pain reconceptualization.

Development of culturally sensitive Pain Neuroscience Education for first-generation Turkish patients with chronic pain: A modified Delphi study

BACKGROUND

Pain Neuroscience Education (PNE) has been recognized as an efficacious approach for chronic pain, but evidence for these findings have mainly been gathered in Caucasian patient populations. In recent years, it has been proposed that the treatment of pain and patient information materials should be culturally sensitive for different ethnic populations and cultures since cultural variations in pain beliefs and cognitions.

OBJECTIVES

To culturally adapt PNE material for first-generation Turkish patients with chronic pain.

DESIGN

A modified Delphi study with three consecutive rounds.

METHOD

A total of 10 participants (8 experts and 2 first-generation Turkish patients with chronic pain) were recruited for this study. Three online questionnaire rounds were conducted to synthesize the perspectives and to reach agreement on the suggested PNE materials.

RESULTS

Results on multiple-choice questions from the first round revealed that the compatibility of the visual information and the clarity of the message obtained lower scores. Examples, visual information (illustrations, pictures), and metaphors in the teaching materials and the home education leaflet were revised based on suggestions in Rounds 1 and 2. In Round 3, respondents reached an acceptable agreement level for the clinical usefulness of the PNE teaching materials and the home education material.

CONCLUSIONS

Culturally sensitive PNE materials were produced for first-generation Turkish patients. Since the results of the present study only reveal perspectives of the experts, further validation of education materials may be required before they are recommended for Turkish patients in clinical practices.

Effect of 12-Week Whole-Body Vibration Exercise on Lumbopelvic Proprioception and Pain Control in Young Adults with Nonspecific Low Back Pain

BACKGROUND Nonspecific low back pain (NSLBP) accounts for a large proportion of low back pain cases. The present study aimed to investigate the effect of the whole-body vibration (WBV) exercise on lumbar proprioception in NSLBP patients. It was hypothesized that WBV exercise enhances lumbar proprioception. MATERIAL AND METHODS Forty-two patients with NSLBP performed an exercise program 3 times a week for a total of 12 weeks of WBV. The lumbar proprioception was measured by joint position sense. Outcomes were lumbar angle deviation and visual analogue scale (VAS) score. RESULTS After the 12-week WBV exercise, lumbar flexion angle deviation was reduced from 3.65±2.26° to 1.90±1.07° (P=0.0001), and extension angle deviation was reduced from 3.06±1.85° to 1.61±0.75° (P=0.0001), significantly lower than baseline. After participating in the 12-week WBV exercise, a significant pain reduction was observed (P=0.0001). Men in the whole group (n=32) indicated significantly lower angle deviations in flexion and extension, whereas women (n=10) indicated significantly lower flexion angle deviation (P=0.037), and no significant difference was found in extension angle deviation (P=0.052). However, by subdividing the entire group (n=42) into poor and good proprioceptive groups, WBV exercise presented significant enhancement of lumbar proprioceptive ability in the poor flexion proprioception subgroup, poor extension proprioception subgroup, and good extension proprioception subgroup (each P=0.0001), but not in the subgroup with good flexion proprioceptive ability (P=0.165). CONCLUSIONS Lumbar flexion and extension proprioception as measured by joint position sense was significantly enhanced and pain was significantly reduced after 12-week WBV exercise in NSLBP patients. However, the patients with good flexion proprioceptive ability had limited proprioceptive enhancement.

A Mechanism-Based Approach to Physical Therapist Management of Pain

Pain reduction is a primary goal of physical therapy for patients who present with acute or persistent pain conditions. The purpose of this review is to describe a mechanism-based approach to physical therapy pain management. It is increasingly clear that patients need to be evaluated for changes in peripheral tissues and nociceptors, neuropathic pain signs and symptoms, reduced central inhibition and enhanced central excitability, psychosocial factors, and alterations of the movement system. In this Perspective, 5 categories of pain mechanisms (nociceptive, central, neuropathic, psychosocial, and movement system) are defined, and principles on how to evaluate signs and symptoms for each mechanism are provided. In addition, the underlying mechanisms targeted by common physical therapist treatments and how they affect each of the 5 categories are described. Several different mechanisms can simultaneously contribute to a patient's pain; alternatively, 1 or 2 primary mechanisms may cause a patient's pain. Further, within a single pain mechanism, there are likely many possible subgroups. For example, reduced central inhibition does not necessarily correlate with enhanced central excitability. To individualize care, common physical therapist interventions, such as education, exercise, manual therapy, and transcutaneous electrical nerve stimulation, can be used to target specific pain mechanisms. Although the evidence elucidating these pain mechanisms will continue to evolve, the approach outlined here provides a conceptual framework for applying new knowledge as advances are made.

Immediate preoperative outcomes of pain neuroscience education for patients undergoing total knee arthroplasty: A case series

BACKGROUND

Standard preoperative education for total knee arthroplasty (TKA) has been shown to have no effect on postoperative outcomes. This may be because such education programs fail to educate patients about pain. Pain neuroscience education (PNE) focuses on teaching people more about pain from a neurobiological and neurophysiological perspective.

DESIGN AND SETTING

Case Series.

AIM

To determine the immediate effects, if any, of providing PNE before TKA surgery on patient self-report measures.

PARTICIPANTS

Twelve patients (female = 10) prior to TKA for knee osteoarthritis (OA).

INTERVENTION

Preoperative educational session by a physical therapist on the neuroscience of pain, accompanied by an evidence-based booklet.

MAIN OUTCOME MEASURES

Comparison of pre- and post-PNE self-report measures on knee pain (NPRS), Pain Catastrophization Scale (PCS), fear of movement (TSK), and beliefs about TKA; as well as three physical performance measures - knee flexion active range of motion, 40 m self-paced walk, and pressure pain threshold (PPT).

RESULTS

Immediately following the PNE, patients had statistically significant lower TSK scores, increased PPT, and improved beliefs about their upcoming surgery. There were no significant changes in knee pain, function, or flexion active range of motion.

CONCLUSIONS

Results appear to suggest that immediately after PNE, patients scheduled for TKA had statistically significant changes in fear of movement, decreased sensitivity to pain and positive shifts in their beliefs about their future knee surgery. Larger trials with control/comparison groups are warranted to determine the true effects of preoperative PNE for patients about to undergo TKA.

Pain Neurophysiology Education and Therapeutic Exercise for Patients With Chronic Low Back Pain: A Single-Blind Randomized Controlled Trial

OBJECTIVE

To assess the effect of a pain neurophysiology education (PNE) program plus therapeutic exercise (TE) for patients with chronic low back pain (CLBP).

DESIGN

Single-blind randomized controlled trial.

SETTING

Private clinic and university.

PARTICIPANTS

Patients with CLBP for ≥6 months (N=56).

INTERVENTIONS

Participants were randomized to receive either a TE program consisting of motor control, stretching, and aerobic exercises (n=28) or the same TE program in addition to a PNE program (n=28), conducted in two 30- to 50-minute sessions in groups of 4 to 6 participants.

MAIN OUTCOMES MEASURES

The primary outcome was pain intensity rated on the numerical pain rating scale which was completed immediately after treatment and at 1- and 3-month follow-up. Secondary outcome measures were pressure pain threshold, finger-to-floor distance, Roland-Morris Disability Questionnaire, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, and Patient Global Impression of Change.

RESULTS

At 3-month follow-up, a large change in pain intensity (numerical pain rating scale: -2.2; -2.93 to -1.28; P<.001; d=1.37) was observed for the PNE plus TE group, and a moderate effect size was observed for the secondary outcome measures.

CONCLUSIONS

Combining PNE with TE resulted in significantly better results for participants with CLBP, with a large effect size, compared with TE alone.

Exercise for chronic musculoskeletal pain: A biopsychosocial approach

Chronic musculoskeletal pain (CMP) refers to ongoing pain felt in the bones, joints and tissues of the body that persists longer than 3 months. For these conditions, it is widely accepted that secondary pathologies or the consequences of persistent pain, including fear of movement, pain catastrophizing, anxiety and nervous system sensitization appear to be the main contributors to pain and disability. While exercise is a primary treatment modality for CMP, the intent is often to improve physical function with less attention to secondary pathologies. Exercise interventions for CMP which address secondary pathologies align with contemporary pain rehabilitation practices and have greater potential to improve patient outcomes above exercise alone. Biopsychosocial treatment which acknowledges and addresses the biological, psychological and social contributions to pain and disability is currently seen as the most efficacious approach to chronic pain. This clinical update discusses key aspects of a biopsychosocial approach concerning exercise prescription for CMP and considers both patient needs and clinician competencies. There is consensus for individualized, supervised exercise based on patient presentation, goals and preference that is perceived as safe and non-threatening to avoid fostering unhelpful associations between physical activity and pain. The weight of evidence supporting exercise for CMP has been provided by aerobic and resistance exercise studies, although there is considerable uncertainty on how to best apply the findings to exercise prescription. In this clinical update, we also provide evidence-based guidance on exercise prescription for CMP through a synthesis of published work within the field of exercise and CMP rehabilitation.

Pain Neuroscience Education: State of the Art and Application in Pediatrics

Chronic pain is a widespread problem in the field of pediatrics. Many interventions to ameliorate pain-related dysfunction have a biobehavioral focus. As treatments for chronic pain (e.g., increased movement) often stand in stark contrast to treatments for an acute injury (e.g., rest), providing a solid rationale for treatment is necessary to gain patient and parent buy-in. Most pain treatment interventions incorporate psychoeducation, or pain neuroscience education (PNE), as an essential component, and in some cases, as a stand-alone approach. The current topical review focuses on the state of pain neuroscience education and its application to pediatric chronic pain. As very little research has examined pain neuroscience education in pediatrics, we aim to describe this emerging area and catalyze further work on this important topic. As the present literature has generally focused on adults with chronic pain, pain neuroscience education merits further attention in the realm of pediatric pain in order to be tailored and implemented in this population.

Therapeutic patient education and exercise therapy in patients with cervicogenic dizziness: a prospective case series clinical study

The purpose of this study was to evaluate the effectiveness of a treatment for patients with cervicogenic dizziness that consisted of therapeutic education and exercises. The Dizziness Handicap Inventory and Neck Disability Index were used. Secondary outcomes included range of motion, postural control, and psychological variables. Seven patients (two males and five females) aged 38.43±14.10 with cervicogenic dizziness were included. All the participants received eight treatment sessions. The treatment was performed twice a week during a four weeks period. Outcome measures included a questionnaire (demographic data, body chart, and questions about pain) and self-reported disability, pain, and psychological variables. Subjects were examined for cervical range of motion and postural control. All of these variables were assessed pre- and postintervention. Participants received eight sessions of therapeutic education patient and therapeutic exercise. The majority of participants showed an improvement in catastrophism (mean change, 11.57±7.13; 95% confidence interval [CI], 4.96–18.17; d=1.60), neck disability (mean change, 5.14±2.27.28; 95% CI, 3.04–7.24; d=1.32), and dizziness disability (mean change, 9.71±6.96; 95% CI, 3.26–16.15; d=1.01). Patients also showed improved range of motion in the right and left side. Therapeutic patient education in combination with therapeutic exercise was an effective treatment. Future research should investigate the efficacy of therapeutic patient education and exercise with larger sample sizes of patients with cervicogenic dizziness.

The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature

OBJECTIVE

Systematic review of randomized control trials (RCTs) for the effectiveness of pain neuroscience education (PNE) on pain, function, disability, psychosocial factors, movement, and healthcare utilization in individuals with chronic musculoskeletal (MSK) pain.

DATA SOURCES

Systematic searches were conducted on 11 databases. Secondary searching (PEARLing) was undertaken, whereby reference lists of the selected articles were reviewed for additional references not identified in the primary search.

STUDY SELECTION

All experimental RCTs evaluating the effect of PNE on chronic MSK pain were considered for inclusion. Additional Limitations: Studies published in English, published within the last 20 years, and patients older than 18 years. No limitations were set on specific outcome measures.

DATA EXTRACTION

Data were extracted using the participants, interventions, comparison, and outcomes (PICO) approach.

DATA SYNTHESIS

Study quality of the 13 RCTs used in this review was assessed by 2 reviewers using the PEDro scale. Narrative summary of results is provided for each study in relation to outcomes measurements and effectiveness.

CONCLUSIONS

Current evidence supports the use of PNE for chronic MSK disorders in reducing pain and improving patient knowledge of pain, improving function and lowering disability, reducing psychosocial factors, enhancing movement, and minimizing healthcare utilization.

Exercise Benefits for Chronic Low Back Pain in Overweight and Obese Individuals

Overweight and obese individuals with chronic low back pain (LBP) struggle with the combined physical challenges of physical activity and pain interference during daily life; perceived disability increases, pain symptoms worsen, and performance of functional tasks and quality of life (QOL) decline. Consistent participation in exercise programs positively affects several factors including musculoskeletal pain, perceptions of disability due to pain, functional ability, QOL, and body composition. It is not yet clear, however, what differential effects occur among different easily accessible exercise modalities in the overweight-obese population with chronic LBP. This narrative review synopsizes available randomized and controlled, or controlled and comparative, studies of easily accessible exercise programs on pain severity, QOL, and other outcomes, such as physical function or body composition change, in overweight-obese persons with chronic LBP. We identified 16 studies (N = 1,351) of various exercise programs (aerobic exercise [AX], resistance exercise [RX], aquatic exercise [AQU], and yoga-Pilates) that measured efficacy on LBP symptoms, and at least one other outcome such as perceived disability, QOL, physical function, and body composition. RX, AQU, and Pilates exercise programs demonstrated the greatest effects on pain reduction, perceived disability, QOL, and other health components. The highest adherence rate occurred with RX and AQU exercise programs, indicating that these types of programs may provide a greater overall impact on relevant outcomes for overweight-obese LBP patients.

LEVEL OF EVIDENCE

V.

Know Pain, Know Gain? A Perspective on Pain Neuroscience Education in Physical Therapy

Chronic pain is incredibly complex, and so are decisions as to its treatment. During physical therapy care, pain neuroscience education (PNE) aims to help patients understand more about their pain from a biological and physiological perspective. Accompanying the growing evidence for the ability of PNE to reduce pain and disability in patients with chronic pain is an increased interest in PNE from scientists, educators, clinicians, and conference organizers. However, the rise in popularity of PNE has highlighted a historical paradox of increased knowledge not necessarily corresponding with improved care. This Viewpoint discusses the growth and popularity of PNE as well as critical future considerations such as clinical application, clinical research, appropriate outcome measures, and the blending of pain education with exercise and manual therapy.