How Much Is Needed? Comparison of the Effectiveness of Different Pain Education Dosages in Patients with Fibromyalgia

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

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

SIGNIFICANCE STATEMENT

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Link between Endogenous Pain Modulation Changes and Clinical Improvement in Fibromyalgia Syndrome: A Meta-Regression Analysis

Conditioned pain modulation (CPM) and temporal summation (TS) tests can measure the ability to inhibit pain in fibromyalgia syndrome (FMS) patients and its level of pain sensitization, respectively. However, their clinical validity is still unclear. We studied the association between changes in the CPM and TS tests and the clinical improvement of FMS patients who received therapeutic intervention. We systematically searched for FMS randomized clinical trials with data on therapeutic interventions comparing clinical improvement (pain intensity and symptom severity reduction), CPM, and TS changes relative to control interventions. To study the relationship between TS/CPM and clinical measures, we performed a meta-regression analysis to calculate odds ratios. We included nine studies (484 participants). We found no significant changes in TS or CPM by studying all the interventions together. Our findings show that this lack of difference is likely because pharmacological and non-pharmacological interventions resulted in contrary effects. Non-pharmacological interventions, such as non-invasive neuromodulation, showed the largest effects normalizing CPM/TS. Meta-regression was significantly associated with pain reduction and symptom severity improvement with normalization of TS and CPM. We demonstrate an association between clinical improvement and TS/CPM normalization in FMS patients. Thus, the TS and CPM tests could be surrogate biomarkers in FMS management. Recovering defective endogenous pain modulation mechanisms by targeted non-pharmacological interventions may help establish long-term clinical recovery in FMS patients.

The Association between Pressure Pain Thresholds, Conditioned Pain Modulation, Clinical Status, and Sleep Quality in Fibromyalgia Patients: A Clinical Trial Secondary Analysis

Background: Fibromyalgia (FM) is a complex multidimensional disorder primarily characterized by chronic widespread pain, significantly affecting patients' quality of life. FM is associated with some clinical signs found with quantitative sensory testing (QST), sleep disturbance, or psychological problems. This study aims to explore the associations between pressure pain thresholds (PPTs), conditioned pain modulation (CPM), clinical status, and sleep quality in FM patients, offering insights for better clinical management and assessment tools. Methods: This secondary analysis utilized data from a clinical trial involving 129 FM patients. Various assessments, including the Fibromyalgia Impact Questionnaire (FIQ), Pain Catastrophizing Scale (PCS), State-Trait Anxiety Inventory (STAI), and Jenkins Sleep Scale (JSS), were employed to evaluate the clinical and psychological status and sleep quality. PPTs and CPM were measured to understand their relationship with clinical parameters. Results: Our findings revealed that PPTs and CPM are not significantly associated with the clinical status or sleep quality of FM patients. Instead, pain catastrophizing and anxiety state showed a stronger correlation with the impact of fibromyalgia and sleep disturbances. These results highlight the importance of psychological and cognitive factors in managing FM. Conclusions: The study suggests that while PPTs and CPM may not be reliable biomarkers for clinical status in FM, the use of comprehensive assessments including FIQ, PCS, STAI, and JSS can provide a more accurate evaluation of patients' condition. These tools are cost-effective, can be self-administered, and facilitate a holistic approach to FM management, emphasizing the need for personalized treatment plans.

Pain neuroscience education improves quality of life when added to aquatic exercise therapy for women with fibromyalgia: randomized controlled clinical trial

PURPOSE

The aim of the present study was to investigate the effects of adding Pain Neuroscience Education (PNE) to an aquatic therapy protocol on pain, fibromyalgia (FMS) impact, quality of life and sleep.

MATERIALS AND METHODS

Seventy-five women were randomly allocated into two groups: aquatic exercises (AEG, n = 36) and aquatic exercises + PNE (PNG, n = 39). The primary outcome was pain, and the secondary outcomes were FMS impact, quality of life, sleep and pain sensitivity (pressure pain thresholds - PPTs). Participants performed 45-min sessions of aquatic exercises, twice a week, for 12 weeks. PNG also received 4 PNE sessions during this period. Participants were assessed four times: initial (before treatment), after 6 weeks (intermediate) and 12 weeks (final) of treatment and after 12 weeks after the end of treatment (follow-up).

RESULTS

Both groups improved pain after treatment, with no difference between them (p > 0.05, partial ƞ2 0.10). FMS impact and PPTs improved after treatment with no difference between groups, and sleep did not change. Quality of life improved several domains for both groups, with slightly better results for the PNG, with low effect sizes between groups.

CONCLUSIONS

The present results show that the addition of PNE to an aquatic exercise intervention did not provide larger effects than aquatic exercises alone for people with FMS concerning pain intensity, but provided benefit for health-related quality of life for this population.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03073642, version 2, April 1st, 2019).

PERSPECTIVE

The addition of 4 Pain Neuroscience Education sessions to an aquatic exercises protocol did not add benefits for women with fibromyalgia syndrome on pain, fibromyalgia impact, and sleep, but improved quality of life and pain sensitivity.IMPLICATIONS FOR REHABILITATIONAquatic exercises are commonly prescribed, but patient education is crucial for the treatment.The addition of Pain Neuroscience Education to an aquatic exercises protocol did not add benefits for women with fibromyalgia syndrome.The positive changes on quality of life and pain sensitivity that this combination led to had small effect sizes and did not achieve minimal important clinical difference.

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.

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.

Examining the influence of pain neuroscience education followed by a Pilates exercises program in individuals with knee osteoarthritis: a pilot randomized controlled trial

BACKGROUND

Knee osteoarthritis (OA) is a multifactorial form of rheumatic condition contributing to physical and psychological factors. Treatments have been provided solely and often compared with each other. An alternative view is that combined treatments addressing physical and psychological factors may result in more benefits. This study aimed to investigate the effect of pain neuroscience education (PNE) followed by Pilates exercises (PEs) in participants with knee OA, compared to PE alone.

METHODS

In this two-arm assessor-blind pilot randomized controlled trial, fifty-four community-dwelling adults with knee OA were randomly assigned to the PNE followed by PEs and PEs groups (27 in each group). The study was conducted between early July 2021 and early March 2022 at the university's health center. Primary outcomes were Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) subscales of pain and physical limitation and secondary outcomes were Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, Pain Self-Efficacy Questionnaire, and Timed "Up & Go" test covering function. The primary and secondary outcomes were measured at baseline and eight weeks post-treatment. A general linear mixed model was used for between-group comparison with a statistical significance level of 0.05.

RESULTS

Significant within-group differences were observed in all outcomes in both groups at post-treatment. There were no statistically between-group differences in pain (adjusted mean difference: -0.8; 95% CI -2.2 to 0.7; p = 0.288), physical limitation (adjusted mean difference: -0.4; 95% CI -4 to 3.1; p = 0.812) and function (adjusted mean difference: -0.8; 95% CI -1.8 to 0.1; p = 0.069) at eight weeks. For pain catastrophizing (adjusted mean difference: -3.9; 95% CI -7.2 to -0.6; p = 0.021), kinesiophobia (adjusted mean difference: -4.2; 95% CI -8.1 to -0.4; p = 0.032), and self-efficacy (adjusted mean difference: 6.1; 95% CI 0.7 to 11.5; p = 0.028) statistically between-group improvements were observed favoring PNE followed by PEs group after the treatment.

CONCLUSIONS

Combining PNE with PEs could have superior effects on psychological characteristics but not on pain, physical limitation, and function, compared to PEs alone. This pilot study emphasizes the need to investigate the combined effects of different interventions.

TRIAL REGISTRATION

IRCT20210701051754N1.

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.

The development and measurement properties of the Dutch version of the fear-avoidance components scale (FACS-D) in persons with chronic musculoskeletal pain

OBJECTIVES

The Fear-Avoidance Components Scale (FACS) is a recently developed patient-reported instrument assessing different constructs related to the fear-avoidance model of pain. The aim was to translate the original English FACS into Dutch (FACS-D) and assess its measurement properties in persons with chronic musculoskeletal pain.

METHODS

The original English FACS (20 item-scale, range: 0-100) was translated in Dutch through standard forward-backward translation methodology. The FACS-D's measurement properties were evaluated in 224 persons with chronic musculoskeletal pain. Internal consistency, test-retest reliability and measurement error were assessed with the Cronbach's alpha coefficient (α), intraclass correlation coefficient (ICC), and standard error of measurement (SEM). Construct validity was assessed through inter-item correlation analyses, exploratory factor analysis, association with other fear-avoidance-related constructs, and hypothesis testing.

RESULTS

Internal consistency, test-retest reliability and hypotheses testing were good (α=0.92; ICC=0.92, CI 0.80-0.96; 7/8 hypotheses confirmed). Similar to the original FACS and other translated versions, a two-factor model best fit the data. However, the item distribution differed from other versions. One factor represented "pain-related cognitions and emotions" and a second factor represented "avoidance behaviour." In contrast to the original FACS, low inter-item correlations for item 12 were found. The FACS-D was more strongly associated with fear-avoidance-related constructs of pain severity, perceived disability, feelings of injustice, and depressive/anxiety symptoms than the other fear-avoidance-related scales studied here.

CONCLUSIONS

The FACS-D demonstrated good reliability and construct validity, suggesting that it may be a useful measure for Dutch-speaking healthcare providers. Two clinically relevant factors, with a different item distribution than the original FACS, were identified: one covering items on pain-related cognitions and emotions, and one covering items on avoidance behaviour. The stronger association between FACS-D and fear-avoidance related constructs suggests that the FACS-D may be more effective in evaluating the cognitive, emotional and behavioural constructs of pain-related fear-avoidance than other similar measures.

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.

Effectiveness, cost-utility and physiological underpinnings of the FIBROWALK multicomponent therapy in online and outdoor format in individuals with fibromyalgia: Study protocol of a randomized, controlled trial (On&Out study)

Introduction: The On&amp;Out study is aimed at assessing the effectiveness, cost-utility and physiological underpinnings of the FIBROWALK multicomponent intervention conducted in two different settings: online (FIBRO-On) or outdoors (FIBRO-Out). Both interventions have proved to be efficacious in the short-term but there is no study assessing their comparative effectiveness nor their long-term effects. For the first time, this study will also evaluate the cost-utility (6-month time-horizon) and the effects on immune-inflammatory biomarkers and Brain-Derived Neurotrophic Factor (BDNF) levels of both interventions. The objectives of this 6-month, randomized, controlled trial (RCT) are 1) to examine the effectiveness and cost-utility of adding FIBRO-On or FIBRO-Out to Treatment-As-Usual (TAU) for individuals with fibromyalgia (FM); 2) to identify pre–post differences in blood biomarker levels in the three study arms and 3) to analyze the role of process variables as mediators of 6-month follow-up clinical outcomes.

Methods and analysis: Participants will be 225 individuals with FM recruited at Vall d’Hebron University Hospital (Barcelona, Spain), randomly allocated to one of the three study arms: TAU vs. TAU + FIBRO-On vs. TAU + FIBRO-Out. A comprehensive assessment to collect functional impairment, pain, fatigue, depressive and anxiety symptoms, perceived stress, central sensitization, physical function, sleep quality, perceived cognitive dysfunction, kinesiophobia, pain catastrophizing, psychological inflexibility in pain and pain knowledge will be conducted pre-intervention, at 6 weeks, post-intervention (12 weeks), and at 6-month follow-up. Changes in immune-inflammatory biomarkers [i.e., IL-6, CXCL8, IL-17A, IL-4, IL-10, and high-sensitivity C-reactive protein (hs-CRP)] and Brain-Derived Neurotrophic Factor will be evaluated in 40 participants in each treatment arm (total n = 120) at pre- and post-treatment. Quality of life and direct and indirect costs will be evaluated at baseline and at 6-month follow-up. Linear mixed-effects regression models using restricted maximum likelihood, mediational models and a full economic evaluation applying bootstrapping techniques, acceptability curves and sensitivity analyses will be computed.

Ethics and dissemination: This study has been approved by the Ethics Committee of the Vall d’Hebron Institute of Research. The results will be actively disseminated through peer-reviewed journals, conference presentations, social media and various community engagement activities. Trial registration number NCT05377567 (clinicaltrials.gov).

Impact of Pain Neuroscience Education Program in Community Physiotherapy Context on Pain Perception and Psychosocial Variables Associated with It in Elderly Persons: A Ranzomized Controlled Trial

This study investigated the long-term effect (six-months) of a Pain Neuroscience Education (PNE) program on pain perception, quality of life, kinesiophobia and catastrophism in older adults with multimorbidity and chronic pain. Fifty participants (n = 50) were randomly assigned to the pain education therapy group (PET; n = 24) and control group (CG; n = 26). The PET group received six sessions (i.e., once a week, 50 min) about neurophysiology of pain while the CG carried on with their usual life. Perception of pain through the visual analogue scale (VAS), quality of life (EQ-5D questionnaire), kinesiophobia (TSK-11) and catastrophism (PCS) were assessed after six months since the last PNE session. Statistically significant differences on VAS (t₍₄₈₎ = 44, p = 0.01, ES = 0.42 [0.13, 0.65]) was found in favor to PET group. No other statistically significant differences were found. This study found that the application of a PNE intervention in an isolated form was able to significantly reduce pain perception with low effect size in the long-term (six months after intervention) in elderly people with chronic pain.

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.

Efficacy of nonpharmacological interventions for individual features of fibromyalgia: a systematic review and meta-analysis of randomised controlled trials

ABSTRACT

Fibromyalgia is a highly heterogeneous condition, but the most common symptoms are widespread pain, fatigue, poor sleep, and low mood. Nonpharmacological interventions are recommended as first-line treatment of fibromyalgia. However which interventions are effective for the different symptoms is not well understood. The objective of this study was to assess the efficacy of nonpharmacological interventions on symptoms and disease-specific quality of life. Seven databases were searched from their inception until June 1, 2020. Randomised controlled trials comparing any nonpharmacological intervention to usual care, waiting list, or placebo in people with fibromyalgia aged >16 years were included without language restriction. Fibromyalgia Impact Questionnaire (FIQ) was the primary outcome measure. Standardised mean difference and 95% confidence interval were calculated using random effects model. The risk of bias was evaluated using the modified Cochrane tool. Of the 16,251 studies identified, 167 randomised controlled trials (n = 11,012) assessing 22 nonpharmacological interventions were included. Exercise, psychological treatments, multidisciplinary modality, balneotherapy, and massage improved FIQ. Subgroup analysis of different exercise interventions found that all forms of exercise improved pain (effect size [ES] -0.72 to -0.96) and depression (ES -0.35 to -1.22) except for flexibility exercise. Mind-body and strengthening exercises improved fatigue (ES -0.77 to -1.00), whereas aerobic and strengthening exercises improved sleep (ES -0.74 to -1.33). Psychological treatments including cognitive behavioural therapy and mindfulness improved FIQ, pain, sleep, and depression (ES -0.35 to -0.55) but not fatigue. The findings of this study suggest that nonpharmacological interventions for fibromyalgia should be individualised according to the predominant symptom.

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.

Recommendations by the Spanish Society of Rheumatology on the management of patients with fibromyalgia. Part II

OBJECTIVE

To prevent the deterioration of patients with fibromyalgia due to potentially avoidable harmful actions in clinical practice.

METHODS

A multidisciplinary panel of experts identified key areas, analysed the scientific evidence and formulated recommendations based on this evidence and qualitative techniques of "formal assessment" or "reasoned judgement".

RESULTS

Thirty-nine recommendations were made on diagnosis, ineffective and unsafe treatments, patient education and practitioner training. This part II shows the 12 recommendations, referring to the latter two areas.

CONCLUSIONS

Good knowledge of fibromyalgia on the part of patients improves their coping and acceptance of the disease and reduces the severity of some clinical manifestations. Healthcare professionals treating patients with fibromyalgia should be well trained in this disease to improve treatment outcomes and patient relationships.

Effectiveness of a group intervention using pain neuroscience education and exercise in women with fibromyalgia: a pragmatic controlled study in primary care

BACKGROUND

Very positive effects have been described in the application of pain neuroscience education (PNE) to chronic pain and migraine. However, there are few data on the applicability of this therapeutic approach in actual clinical practice in a primary care (PC) setting. The aim of this study was to explore the efficacy in fibromyalgia (FM) of an intervention based on PNE and exercise compared to treatment as usual (TAU).

METHODS

Pragmatic nonrandomised controlled trial set in 5 healthcare centres and one physiotherapy centre in PC. Fifty-three women with FM (2010 American College of Rheumatology Diagnostic Criteria for Fibromyalgia) were studied, 35 in the intervention group (IG) and 18 in the control group (CG). The women in the IG were interviewed individually and then received 6 weekly sessions plus one review session (1 month later): those in the CG received their TAU. The subject assignation to the CG or the IG was determined according to their availability to attend the sessions. They all filled in several questionnaires (prior to and 1 year after the intervention) to evaluate the impact of FM in their daily lives, catastrophism, anxiety and depression, severity and impact of pain in daily personal performance and functional capacity.

RESULTS

The reductions (improvements) in the scores of all tests (baseline-final) were greater in the IG (p < 0.05) when adjusted for age and baseline values, with moderate or high effect size. After 1 year, 20% (CI - 1 to 42%) more women in the IG, compared to the CG, had a FIQ score < 39 (mild functional impairment). 17/38 (49%) women in the IG no longer met FM criteria at the end of follow-up.

CONCLUSIONS

An intervention based on PNE and exercise in patients with FM is feasible and seems effective in PC.

TRIAL REGISTRATION

The study was retrospectively registered at ClinicalTrials.gov (Trial Registration NCT04539171 ), on 04/09/2020.

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.

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 (PRISMA-ScR) Co-author (TR), a Medical Librarian, searched the MEDLINE, PsychInfo, Embase & 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.

Improvement in pain interference and function by an allied health pain management program: Results of a randomized trial

BACKGROUND

Chronic pain is a significant health problem worldwide and requires a biopsychosocial treatment approach. Access to traditional pain medicine specialist services is limited and innovative treatment models are required to support patients in tertiary care. The study evaluated the clinical effectiveness and safety of the Treatment Access Pathway (TAP), an allied health expanded scope model of care which included innovative group assessment and collaboration with patients to create individualized treatment plans.

METHODS

One hundred and eighty-one patients referred to a tertiary level chronic pain service were randomly allocated to either the TAP or the waitlist study groups. Primary (pain interference) and secondary outcome measures were collected at recruitment and again at 6 months. Per-protocol analyses were utilized due to high participant attrition (46% across groups).

RESULTS

The TAP group reported greater reductions in pain interference at 6 months than waitlist group (0.9, 95% CI: 0.2-1.6), with more than half of the TAP group (52%) reporting clinically significant improvement. In addition, statistically significant differences between the TAP and waitlist groups were observed for objective measurements of walking endurance (5.4 m, 95% CI: 1.7-9.1); and global impressions of change (1.4 unit decrease, 95% CI: 1-1.9). Nil adverse events were recorded.

CONCLUSIONS

The study suggests that an expanded scope allied health model of care prioritizing patient choice and group-based interventions provides modest benefits for tertiary-referral chronic pain patients. TAP warrants further investigation as a potentially viable alternative for tertiary healthcare where traditional pain services are unavailable or have long waiting lists.

SIGNIFICANCE

The study tests effectiveness and safety of an expanded scope allied health-led chronic pain program. Despite a high attrition rate, the study showed reduced pain interference and increased physical function in those who completed the protocol. The results are promising and support introduction of this model as an adjunct to existing traditional chronic pain models of care, with a particular focus on improving participant retention in the program. Additionally, the model of care can be used as a standalone chronic pain model of care where no other pain management resources are available. The study was registered on ANZCTR (Trial ID: ACTRN12617001284358).

Intervention Therapies to Reduce Pain-Related Fear in Fibromyalgia Syndrome: A Systematic Review of Randomized Clinical Trials

OBJECTIVE

This systematic review aimed to evaluate the effectiveness of different interventions at reducing pain-related fear in people with fibromyalgia and to analyze whether the included trials reported their interventions in full detail.

DESIGN

Systematic review.

SETTING

No restrictions.

METHODS

The Cochrane Library, CINAHL, EMBASE, PsycINFO, PubMed, and Scopus were searched from their inception to April 2020, along with manual searches and a gray literature search. Randomized clinical trials were included if they assessed pain-related fear constructs as the primary or secondary outcome in adults with fibromyalgia. Two reviewers independently performed the study selection, data extraction, risk-of-bias assessment, Template for Intervention Description and Replication (TIDieR) checklist assessment, and grading the quality of evidence.

RESULTS

Twelve randomized clinical trials satisfied the eligibility criteria, including 11 cohorts with a total sample of 1,441 participants. Exercise, multicomponent, and psychological interventions were more effective than controls were in reducing kinesiophobia. However, there were no differences in decreasing kinesiophobia when self-management and electrotherapy were used. There were also no differences between groups with regard to the rest of the interventions and pain-related constructs (fear-avoidance beliefs, fear of pain, and pain-related anxiety). However, a serious risk of bias and a very serious risk of imprecision were detected across the included trials. This caused the overall certainty of the judged evidence to be low and very low. Additionally, the included trials reported insufficient details to allow the full replication of their interventions.

CONCLUSIONS

This systematic review shows that there are promising interventions, such as exercise, multicomponent, and psychological therapies, that may decrease one specific type of fear in people with fibromyalgia, i.e., kinesiophobia. However, because of the low-very low certainty of the evidence found, a call for action is needed to improve the quality of randomized clinical trials, which will lead to more definitive information about the clinical efficacy of interventions in this field.

Recommendations by the Spanish Society of Rheumatology on the Management of Patients with Fibromyalgia. Part II

OBJECTIVE

To prevent the deterioration of patients with fibromyalgia due to potentially avoidable harmful actions in clinical practice.

METHODS

A multidisciplinary panel of experts identified key areas, analysed the scientific evidence and formulated recommendations based on this evidence and qualitative techniques of «formal assessment» or «reasoned judgement».

RESULTS

Thirty-nine recommendations were made on diagnosis, ineffective and unsafe treatments, patient education and practitioner training. This partII shows the 12 recommendations, referring to the latter two areas.

CONCLUSIONS

Good knowledge of fibromyalgia on the part of patients improves their coping and acceptance of the disease and reduces the severity of some clinical manifestations. Healthcare professionals treating patients with fibromyalgia should be well trained in this disease to improve treatment outcomes and patient relationships.

Association of Gender, Painkiller Use, and Experienced Pain with Pain-Related Fear and Anxiety among University Students According to the Fear of Pain Questionnaire-9

Anxiety and fear are determinants of acute and chronic pain. Effectively measuring fear associated with pain is critical for identifying individuals’ vulnerable to pain. This study aimed to assess fear of pain among students and evaluate factors associated with pain-related fear. We used the Fear of Pain Questionnaire-9 to measure this fear. We searched for factors associated with fear of pain: gender, size of the city where the subjects lived, subject of academic study, year of study, the greatest extent of experienced pain, frequency of painkiller use, presence of chronic or mental illness, and past hospitalization. We enrolled 717 participants. Median fear of minor pain was 5 (4–7) fear of medical pain 7 (5–9), fear of severe pain 10 (8–12), and overall fear of pain 22 (19–26). Fear of pain was associated with gender, frequency of painkiller use, and previously experienced pain intensity. We found a correlation between the greatest pain the participant can remember and fear of minor pain (r = 0.112), fear of medical pain (r = 0.116), and overall fear of pain (r = 0.133). Participants studying medicine had the lowest fear of minor pain while stomatology students had the lowest fear of medical pain. As students advanced in their studies, their fear of medical pain lowered. Addressing fear of pain according to sex of the patient, frequency of painkiller use, and greatest extent of experienced pain could ameliorate medical training and improve the quality of pain management in patients.

Effectiveness of Pain Neurophysiology Education on Musculoskeletal Pain: A Systematic Review and Meta-Analysis

Objectives

To estimate the effectiveness and safety of Pain Neurophysiology Education (PNE) on pain, disability, and psychological distress at post-intervention and long-term (closest to twelve months after initiating the intervention) in musculoskeletal pain (MSKP).

Methods

Randomized Controlled Trials (RCT) were identified in six engines, reference lists, ClinicalTrials.gov, and by contacting key researches. Risk of bias was assessed using Cochrane Collaboration Risk of Bias Tool 2.0. Meta-analyses, using Restricted Maximum Likelihood Method, were conducted to estimate standardized mean differences (SMD) and overall quality of evidence was evaluated according to GRADE.

Results

In total, 18 RCTs (n = 1,585) were included. There was small to moderate effects of PNE on pain at post-intervention and long-term: SMD = -0.32 (95% confidence interval [CI]: −.58; −.05) and SMD = −0.40 (95% CI: −.78; −.03), respectively. On disability, PNE had a small effect at post-intervention: SMD = -0.17 (95% CI: −.34; −.01) but was insignificant at long-term: SMD = −0.27 (95% CI: −.59; .06). Likewise, there was a small to moderate effect on psychological distress at post-intervention: SMD = −0.36 (95% CI: −.67; −.06) but was insignificant at long-term: SMD = −0.37 (95% CI: −.75; .01). Quality of evidence was low across all outcomes. Additional analyses showed significant effects of PNE, corresponding to moderate effects, on pain and psychological distress at both time points in chronic MSKP.

Conclusions

Overall quality of evidence was low, supporting PNE being safe and having small to moderate effects on pain at both time points, and on disability as well as psychological distress at post-intervention.

Effectiveness of Unihemispheric Concurrent Dual-Site Stimulation over M1 and Dorsolateral Prefrontal Cortex Stimulation on Pain Processing: A Triple Blind Cross-Over Control Trial

BACKGROUND

Transcranial direct current stimulation (tDCS) of the motor cortex (M1) produces short-term inhibition of pain. Unihemispheric concurrent dual-site tDCS (UHCDS-tDCS) over the M1 and dorsolateral prefrontal cortex (DLPFC) has greater effects on cortical excitability than when applied alone, although its effect on pain is unknown. The aim of this study was to test if anodal UHCDS-tDCS over the M1 and DLPFC in healthy participants could potentiate conditioned pain modulation (CPM) and diminish pain temporal summation (TS).

METHODS

Thirty participants were randomized to receive a sequence of UHCDS-tDCS, M1-tDCS and sham-tDCS. A 20 min 0.1 mA/cm2 anodal or sham-tDCS intervention was applied to each participant during three test sessions, according to a triple-blind cross-over trial design. For the assessment of pain processing before and after tDCS intervention, the following tests were performed: tourniquet conditioned pain modulation (CPM), pressure pain temporal summation (TS), pressure pain thresholds (PPTs), pressure pain tolerance, mechanosensitivity and cold hyperalgesia. Motor function before and after tDCS intervention was assessed with a dynamometer to measure maximal isometric grip strength.

RESULTS

No statistically significant differences were found between groups for CPM, pressure pain TS, PPT, pressure pain tolerance, neural mechanosensitivity, cold hyperalgesia or grip strength (p > 0.05).

CONCLUSIONS

Neither UHCDS-tDCS nor M1-tDCS facilitated CPM or inhibited TS in healthy subjects following one intervention session.

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.

Effect of Additional Pain Neuroscience Education in Interdisciplinary Multimodal Pain Therapy on Current Pain. A Non-Randomized, Controlled Intervention Study

Purpose

Interdisciplinary multimodal pain therapy (IMPT) programs for chronic back pain are effective and recommended. The patient-centered and biopsychosocial nature of IMPT is grounded in contemporary understanding that chronic pain states reflect heightened sensitization of the nervous system rather than an issue in the tissue. Teaching patients about pain is part of IMPT programs, though a clinical guideline is lacking. This study aims to answer the following question: Does the addition of an evidence-based pain neuroscience education (PNE) lecture for patients, into an IMPT program, produce superior results than the IMPT program itself?

Patients and Methods

A non-randomized, controlled intervention study was performed with 179 back pain patients indicated for IMPT. Intervention group (N=102) received a four-week IMPT program, which contained 4 one-hour sessions PNE. Control group (N=77) received the same IMPT without the additional PNE. Primary outcome was current pain after intervention. Pain knowledge, physical function, depression, anxiety, stress, quality of life and fear-avoidance were analyzed as secondary outcomes. Outcomes were defined as change of the parameter measured before and immediately after the four-week IMPT. For each outcome, linear regression models were used to estimate the raw and adjusted (sex, age and BMI) effect of additional PNE.

Results

Despite improvement in all outcomes for both groups during the treatment phase, the implemented PNE did not result in additional pain reduction (regression coefficient for PNE effect on pain level 0.34; 95% CI −6.23–6.97). Between-group differences could only be shown for pain-related knowledge in favor for the intervention group (0.78; 95% CI 0.35–1.20).

Conclusion

The additional PNE lecture did not lead to pain reduction beyond the usual IMPT. However, the PNE did increase pain-related knowledge and, therefore, might be helpful in coping with pain after the IMPT program.

Therapeutic Exercise and Pain Neurophysiology Education in Female Patients with Fibromyalgia Syndrome: A Feasibility Study

Background: We compared the effects of therapeutic exercise (TE) combined with pain neurophysiology education (PNE) to those of TE in isolation on pain intensity, general fibromyalgia impact, mechanical pain sensitivity, pain catastrophizing, psychological distress and quality of life in women with fibromyalgia syndrome (FMS). Methods: A feasibility study with a 3 month follow-up was designed. Thirty-two patients with FMS were randomly assigned to PNE + TE group (n = 16) or to TE group (n = 16). Both groups received 30 sessions of TE (3 per week), and the PNE + TE group received eight face-to-face educational sessions. The measuring instruments used were the visual analogue scale, a standard pressure algometer, the Revised Fibromyalgia Impact Questionnaire, the Pain Catastrophizing Scale, the Hospital Anxiety and Depression Scale and the Health Assessment Questionnaire. Results: The PNE + TE group showed a statistically significant decrease on pain intensity compared to TE group at short term (p = 0.015). No between-groups differences were found for mechanical pain sensitivity, general fibromyalgia impact, pain catastrophizing, psychological distress or quality of life (p > 0.05). Conclusions: The combination of PNE and TE was more effective than TE for reducing pain intensity in the short-term. No differences were found for psychological distress, pain catastrophizing and quality of life after the intervention or at 3 months of follow-up.

Mindfulness-Based Program Plus Amygdala and Insula Retraining (MAIR) for the Treatment of Women with Fibromyalgia: A Pilot Randomized Controlled Trial

The lack of highly effective treatments for fibromyalgia (FM) represents a great challenge for public health. The objective of this parallel, pilot randomized controlled trial (RCT) was two-fold: (1) to analyze the clinical effects of mindfulness plus amygdala and insula retraining (MAIR) compared to a structurally equivalent active control group of relaxation therapy (RT) in the treatment of FM; and (2) to evaluate its impact on immune-inflammatory markers and brain-derived neurotrophic factor (BDNF) in serum. A total of 41 FM patients were randomized into two study arms: MAIR (intervention group) and RT (active control group), both as add-ons of treatment as usual. MAIR demonstrated significantly greater reductions in functional impairment, anxiety, and depression, as well as higher improvements in mindfulness, and self-compassion at post-treatment and follow-up, with moderate to large effect sizes. Significant decreases in pain catastrophizing and psychological inflexibility and improvements in clinical severity and health-related quality of life were found at follow-up, but not at post-treatment, showing large effect sizes. The number needed to treat was three based on the criteria of ≥50% Fibromyalgia Impact Questionnaire (FIQ) reduction post-treatment. Compared to RT, the MAIR showed significant decreases in BDNF. No effect of MAIR was observed in immune-inflammatory biomarkers (i.e., TNF-α, IL-6, IL-10, and hs-CRP). In conclusion, these results suggest that MAIR, as an adjuvant of treatment-as-usual (TAU), appears to be effective for the management of FM symptoms and for reducing BDNF levels in serum.

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

Chronic musculoskeletal pain affects more than 20% of the population, leading to high health care overload and huge spending. The prevalence is increasing and negatively affects both physical and mental health, being one of the leading causes of disability. The most common location is the spine. Most treatments used in the Public Health Services are passive (pharmacological and invasive) and do not comply with current clinical guidelines, which recommend treating pain in primary care (PC) with education and exercise as the first-line treatments. A randomized multicentre clinical trial has been carried out in 12 PC centres. The experimental group (EG) conducted a program of pain neuroscience education (6 sessions, 10 h) and group physical exercise with playful, dual-tasking, and socialization-promoting components (18 sessions in 6 weeks, 18 h), and the control group performed the usual physiotherapy care performed in PC. The experimental treatment improved quality of life (d = 1.8 in physical component summary), catastrophism (d = 1.7), kinesiophobia (d = 1.8), central sensitization (d = 1.4), disability (d = 1.4), pain intensity (d = 3.3), and pressure pain thresholds (d = 2). Differences between the groups (p < 0.001) were clinically relevant in favour of the EG. Improvements post-intervention (week 11) were maintained at six months. The experimental treatment generates high levels of satisfaction.

Efficacy of a Multicomponent Intervention for Fibromyalgia Based on Pain Neuroscience Education, Exercise Therapy, Psychological Support, and Nature Exposure (NAT-FM): Study Protocol of a Randomized Controlled Trial

The study protocol of a prospective and randomized controlled trial for the assessment of the efficacy of nature activity therapy for people with Fibromyalgia (NAT-FM) is described. The primary outcome is the mean change from baseline in the Revised Fibromyalgia Impact Questionnaire (FIQR) score at post-treatment (12 weeks) and at 9 months of follow-up, and secondary outcomes are changes in the positive affect, negative affect, pain, fatigue, self-efficacy, catastrophising, and emotional regulation. A total of 160 patients with fibromyalgia will be divided into two arms: treatment-as-usual (TAU) and NAT-FM+TAU. Pre, during, post, +6, and +9 months assessments will be carried out, as well as an ecological momentary assessment (EMA) of intrasession and intersessions. Results will be subjected to a mixed group (NAT-FM+TAU vs. TAU) × phase (pre, post, +6 months, +9 months) general linear model. EMA intrasession measurements will be subjected to a 2 (pre vs. post) × 5 (type of activity) mixed-effects ANOVA. EMA between-session measurements obtained from both arms of the study will be analysed on both a time-domain and frequency-domain basis. Effect sizes and number needed to treat (NNT) will be computed. A mediation/moderation analysis will be conducted.