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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

PRACTICAL IMPLICATIONS

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

Effect of physical activity education on shoulder girdle pain and muscle strength in participants with fibromyalgia: a pilot experimental study

Background

In patients with fibromyalgia, exercise and education are recommended to decrease pain level and improve pain management. The latest scientific evidence recommends to focus interventions on the upper limb. The aim of this pilot study was to compare the immediate effect of physical activity education vs. a control group on pain and muscle capacity in fibromyalgia patients.

Method

Fifty-six participants with fibromyalgia were randomized into an experimental group and a control group. The intervention consisted in watching a five-minute video that provided information about fibromyalgia, pain, kinesiophobia and physical activity. The control group watched a neutral five-minute video about beavers in Quebec. Following the video, participants performed a muscular fatigue task consisting of a repeated unilateral shoulder abduction task. At baseline and following the muscular fatigue task, maximal voluntary contraction (MVC) in shoulder abduction was assessed as well as pain level and pressure pain threshold (PPT) in the upper limb. Electromyographic activity was also assessed for upper trapezius and middle deltoid muscles. Two-way repeated measures analysis of variance was used to compare the MVC, PPT, and pain level before and after the muscular fatigue task between groups.

Results

The experimental group showed a significantly lower increase in pain than the control group in the middle deltoid muscle (p = 0.002) when assessed by verbal pain rating scale. No significant interaction or main effect of Group and Time were observed for the pain level at the upper trapezius and elbow extensor muscles nor for any of the PPT measures. According to electromyographic data, the median frequency values indicate that neither group experienced muscle fatigue during the repeated contraction task.

Conclusions

The preliminary results suggest that a short physical activity education video positively influenced middle deltoid pain following repeated abduction in participants with fibromyalgia. Electromyographic analysis showed no evidence of objective muscle fatigue, suggesting that there might be a partial disconnection between the perception of muscle fatigue and the physiological biomarkers associated with muscle fatigue.

Explaining a diagnosis of fibromyalgia in primary care: a scoping review

BACKGROUND

Fibromyalgia is a common cause of chronic pain in the UK, with a huge individual and societal impact. Despite this, it remains difficult to diagnose and treat. The explanation of a fibromyalgia diagnosis can lead to difficult therapeutic relationships, with attitudinal issues and negative profiling of patients. This can lead to frustration, and have a harmful impact on health outcomes.

AIM

To review how an explanation of a fibromyalgia diagnosis is provided in primary care in order to establish a model of best practice when educating patients on their diagnosis.

DESIGN & SETTING

Scoping review of articles written in English.

METHOD

MEDLINE, Embase, Web of Science, and grey literature were searched. Articles were extracted, reviewed, and analysed according to the inclusion criteria.

RESULTS

In total, 29 records met the inclusion criteria. The following six overarching themes were identified: patient education; physician education; importance of the multidisciplinary team; importance of patient-centred care; the value of primary care; and useful resources. The literature illustrated that describing fibromyalgia using analogies to illustrate the pain sensitisation process can help patients understand their diagnosis better. This improves their willingness to accept management plans, particularly engagement with non-pharmacological therapies, which the literature suggested are best delivered within a multidisciplinary team.

CONCLUSION

Key aspects of fibromyalgia should be explained to patients in order for them to gain a better understanding of their diagnosis. A 'one-size-fits-all' model for explaining the fibromyalgia diagnosis to patients is inappropriate because patients' experiences are individualised. Further research is required on whether different explanations impact patient outcomes.

Effectiveness of patient education as a stand-alone intervention for patients with chronic widespread pain and fibromyalgia: a systematic review and meta-analysis of randomized trials

OBJECTIVE

Patient education is recommended as an integral component of the therapeutic plan for the management of chronic widespread pain (CWP) and fibromyalgia (FM). The key purpose of patient education is to increase the patient's competence to manage his or her own health requirements, encouraging self-management and a return to desired everyday activities and lifestyle. The aim of this systematic review was to evaluate the evidence for the benefits and potential harms associated with the use of patient education as a stand-alone intervention for individuals with CWP and FM through randomized controlled trials (RCTs).

METHOD

On 24 November 2021 a systematic search of PubMed, MEDLINE, Embase, CENTRAL, PsycINFO, CINAHL, ClinicalTrials.gov, American College of Rheumatology, European League Against Rheumatism, and the World Health Organization International Clinical Trials Registry Platform identified 2069 studies. After full-text screening, five RCT studies were found to be eligible for the qualitative evidence synthesis.

RESULTS

Patient education as a stand-alone intervention presented an improvement in patients' global assessment (standardized mean difference 0.79, 95% confidence interval 0.13 to 1.46). When comparing patient education with usual care, no intervention, or waiting list, no differences were found for functioning, level of pain, emotional distress in regard to anxiety and depression, or pain cognition.

CONCLUSION

This review reveals the need for RCTs investigating patient education as a stand-alone intervention for patients with FM, measuring outcomes such as disease acceptance, health-related quality of life, enhancement of patients' knowledge of pain, pain coping skills, and evaluation of prioritized learning outcomes.

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.

Effectiveness of adding pain neuroscience education to telerehabilitation in patients with carpal tunnel syndrome: A randomized controlled trial

BACKGROUND

Previous studies have shown positive results of pain neuroscience education (PNE) combined with exercise in patients with chronic musculoskeletal disorders. However, the effects of this intervention in patients with carpal tunnel syndrome (CTS) admitted to a telerehabilitation program remain unexplored.

OBJECTIVE

To compare the effectiveness of a 6-week telerehabilitation program based on PNE + exercise versus exercise alone on patient-reported outcomes after treatment and at 6-weeks post-treatment follow-up in patients with CTS awaiting surgery.

DESIGN

Randomized controlled trial.

METHODS

Thirty participants were randomly assigned to the PNE + exercise or exercise-only group. Outcome measures included pain intensity, pain catastrophizing, kinesiophobia, symptom severity, function, symptoms of anxiety and depression, quality of life, self-perception of improvement. Inferential analyses of the data were performed using a two-factor mixed analysis of variance.

RESULTS

Twenty-five participants completed the study. A significant time × group interaction with a large effect size was observed for kinesiophobia (F = 6.67, p = 0.005, ηp2 = 0.225) and symptom severity (F = 4.82, p = 0.013, ηp2 = 0.173). No significant interaction was observed for the other variables (p > 0.05). A significant difference in self-perceived improvement was observed in favor of the PNE + exercise group after treatment (p < 0.05). Although there were significant and clinically relevant improvements within the PNE + exercise group in pain intensity and catastrophizing, there were no significant differences between the groups.

CONCLUSIONS

The addition of PNE to a telerehabilitation exercise program showed short-term improvements in kinesiophobia and symptom severity and greater self-perceived improvement in patients with CTS awaiting surgery. This study highlighted the benefits of including PNE in telerehabilitation interventions for patients with CTS.

Are OMERACT recommendations followed in clinical trials on fibromyalgia? A systematic review of patient-reported outcomes and their measures

PURPOSE

Patient-Reported Outcomes (PROs) and its measures (PROMs) are key to outcome assessment in Fibromyalgia (FM) trials. The aim of this review was to investigate which domains and instruments were assessed in recent FM trials and to compare them to recommendations by the Outcome Measures in Rheumatology (OMERACT) initiative. In addition, we investigated the overlap with a generic health assessment approach, i.e. eight domains suggested by the Patient-Reported Outcome Measurement Information System® (PROMIS®).

METHODS

In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic literature search in scientific databases including PubMed, PsycInfo, and Embase was conducted to identify studies that assessed at least two dimensions of health-related quality of life (HRQoL) from 2015 to June 2022. Non-randomized and randomized controlled trials were included in the analysis. We extracted PROs and PROMs used in each study.

RESULTS

From 1845 identified records, 107 records out of 105 studies met the inclusion criteria. Studies investigated 50 PROs using 126 different PROMs. Most frequently assessed domains were pain, depression, fatigue, and anxiety (> 95% of the studies). The disease-specific FIQ was the most frequently applied PROM (82%). Overall, only 9% of the studies covered all domains deemed mandatory by OMERACT. Very few studies covered all eight generic health domains suggested by PROMIS.

CONCLUSION

The majority of trials covered most OMERACT domains or generic PROMIS health domains. There was, however, great variability in the instruments used to assess the domains, which points at a limited degree of standardization in the field.

A Call for Improving Research on Pain Neuroscience Education and Chronic Pain: An Overview of Systematic Reviews

OBJECTIVE: We aimed to summarize the evidence of the effects of pain neuroscience education delivered alone or combined with other interventions for chronic pain. DESIGN: An overview of systematic reviews with meta-analysis. LITERATURE SEARCH: CINAHL (via EBSCOhost), Embase, PsycINFO (via ProQuest), PubMed, and the Cochrane Library were searched from their inception to November 14, 2022. STUDY SELECTION CRITERIA: Systematic reviews (SRs) with meta-analyses including randomized clinical trials. The outcomes were pain and psychological symptoms. DATA SYNTHESIS: AMSTAR 2 assessed the methodological quality of SRs. The primary study overlap was evaluated by calculating the corrected covered area (CCA). RESULTS: We included 8 SRs including 30 meta-analyses of interest that comprised 28 distinct clinical trials. In some meta-analyses, pain neuroscience education delivered alone or combined with other interventions was more effective than control interventions for reducing pain intensity, pain catastrophizing, kinesiophobia, anxiety symptoms, and depression symptoms at some time points. However, other meta-analyses found a lack of effects of pain neuroscience education, and there were inconsistencies between meta-analyses covering the same outcome. The methodological quality of all SRs was critically low. The overlap, including all SRs, was high (CCA = 13%), and very high for SRs covering trials on chronic low back pain (CCA = 40%), chronic spine pain (CCA = 27%), and fibromyalgia (CCA = 25%). CONCLUSION: It is impossible to make clear clinical recommendations for delivering pain neuroscience education based on current meta-analyses. Action is needed to increase and improve the quality of SRs in the field of pain neuroscience education. J Orthop Sports Phys Ther 2023;53(6):1-16. Epub: 10 May 2023. doi:10.2519/jospt.2023.11833.

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.

Effectiveness of two video-based multicomponent treatments for fibromyalgia: The added value of cognitive restructuring and mindfulness in a three-arm randomised controlled trial

BACKGROUND/OBJECTIVES

The aim of this study was to examine the effectiveness of two video-based multicomponent programs (FIBROWALK) and the Multicomponent Physiotherapy Program (MPP) for patients with fibromyalgia (FM) compared to treatment-as-usual (TAU) only. We posit that FIBROWALK, due to inclusion of specific psychological ingredients (cognitive restructuring and mindfulness), can produce additional clinical benefits when compared to TAU or MPP alone.

METHODS

A total of 330 patients with FM were recruited and randomly allocated (1:1:1) to TAU only, TAU + FIBROWALK, or TAU + MPP. FIBROWALK and MPP consisted of weekly videos on pain neuroscience education, therapeutic exercise and self-management patient education, but only the FIBROWALK intervention provided cognitive restructuring and mindfulness. Both programs were structurally equivalent. Between-group differences in functional impairment, pain, kinesiophobia, anxious-depressive symptoms and physical functioning were evaluated at post-treatment following Intention-To-Treat and complete-case approaches.

RESULTS

Compared to TAU only, individuals in the FIBROWALK arm showed larger improvements in all clinical outcomes; similarly, participants in the MPP program also showed greater improvements in functional impairment, perceived pain, kinesiophobia, depressive symptoms compared to TAU only. The FIBROWALK intervention showed superior effects in improving pain, anxiety and depressive symptoms and physical functioning compared to MPP.

CONCLUSIONS

This RCT supports the short-term effectiveness of the video-based multicomponent programs FIBROWALK and MPP for FM and provides evidence that cognitive-behavioural and mindfulness-based techniques can be clinically useful in the context of physiotherapeutic multicomponent treatment programs.

TRIAL REGISTRATION NUMBER

NCT04571528.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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.

Efficacy of the FIBROWALK Multicomponent Program Moved to a Virtual Setting for Patients with Fibromyalgia during the COVID-19 Pandemic: A Proof-of-Concept RCT Performed Alongside the State of Alarm in Spain

FIBROWALK is a multicomponent program including pain neuroscience education, therapeutic exercise, cognitive behavioral therapy and mindfulness training that has recently been found to be effective in patients with fibromyalgia (FM). This RCT started before the COVID-19 pandemic and was moved to a virtual format (i.e., online videos) when the lockdown was declared in Spain. This study is aimed to evaluate the efficacy of a virtual FIBROWALK compared to Treatment-As-Usual (TAU) in patients with FM during the first state of alarm in Spain. A total of 151 patients with FM were randomized into two study arms: FIBROWALK plus TAU vs. TAU alone. The primary outcome was functional impairment. Secondary outcomes were kinesiophobia, anxiety and depressive symptomatology, and physical functioning. Differences between groups at post-treatment assessment were analyzed using Intention-To-Treat (ITT) and completer approaches. Baseline differences between clinical responders and non-responders were also explored. Statistically significant improvements with small-to-moderate effect sizes were observed in FIBROWALK+TAU vs. TAU regarding functional impairment and most secondary outcomes. In our study, the NNT was 5, which was, albeit modestly, indicative of an efficacious intervention. The results of this proof-of-concept RCT preliminarily support the efficacy of virtual FIBROWALK in patients with FM during the Spanish COVID-19 lockdown.

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

Background

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

Methods

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

Results

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

Conclusions

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

Significance

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