Blended-Learning Pain Neuroscience Education and Exercise in High School Students With Chronic Neck Pain: A Randomized Controlled Trial

How do the target concepts of pain science education combined with exercise contribute to the effect on pain intensity and disability in patients with chronic spinal pain? A systematic review and meta-analysis with moderator analysis

The aim of this study was to assess the moderator effect of the target concepts covered in the Pain science education (PSE) sessions, including both the total amount of target concepts and each individual target concept, on changes in pain intensity and disability in patients with chronic spinal pain (CSP). A systematic search of PubMed, Scopus, Embase, Web of Science and CENTRAL was conducted from inception to March 10, 2024. A random effects model was used for meta-regression analysis. A total of 11 studies were included. The total amount of target concepts of PSE showed a significant correlation with changes in pain intensity (k=11; F=4.45; p=0.04; R2=26.07 %). In terms of each target content, only a significant effect on pain intensity was obtained for 'transfer knowledge about pain to an adaptive behavioural change' (z=-2.35, P =0.019, 95 %CI -3.42 to -0.31) and 'reconceptualization of pain' (z=-2.43, P =0.015, 95 %CI -3.70 to -0.39). No significant effect on disability was found. These results may be useful for optimising the effectiveness of PSE programmes.

The optimal dose of pain neuroscience education added to an exercise programme for patients with chronic spinal pain: a systematic review and dose-response meta-analysis

ABSTRACT

Pain neuroscience education (PNE) has shown promising results in the management of patients with chronic spinal pain (CSP). However, no previous review has determined the optimal dose of PNE added to an exercise programme to achieve clinically relevant improvements. The aim was to determine the dose-response association between PNE added to an exercise programme and improvements in pain intensity and disability in patients with CSP. A systematic search of PubMed/MEDLINE, Embase, Web of Science, Scopus, and the Cochrane Library was conducted from inception to April 19, 2023. The exposure variable (dosage) was the total minutes of PNE. Outcome measures included pain intensity, disability, quality of life, pressure pain thresholds, and central sensitization inventory. Data extraction, risk-of-bias assessment, and certainty of evidence were performed by 2 independent reviewers. The dose-response relationship was assessed using a restricted cubic spline model. Twenty-six randomised controlled trials with 1852 patients were included. Meta-analysis revealed a statistically significant effect in favour of PNE on pain intensity and disability. In addition, a dose of 200 and 150 minutes of PNE added to an exercise programme was estimated to exceed the minimum clinically important difference described in the literature for pain intensity (-2.61 points, 95% CI = -3.12 to -2.10) and disability (-6.84 points, 95% CI = -7.98 to -5.70), respectively. The pooled effect of the isolated exercise was small. These findings may be useful in optimising the most appropriate PNE dose to achieve clinically relevant improvements in patients with CSP.

Correlations of The Central Sensitization Inventory, conditioned pain modulation, cognitions and psychological factors in individuals with chronic neck pain: A cross-sectional study

INTRODUCTION

Chronic neck pain (CNP) is a global public health problem, with high prevalence and absenteeism rates. Central sensitization (CS) as a basis for chronic pain may play an essential role in its development and progression. It is often comorbid with low conditioned pain modulation (CPM) effects, cognitions, and psychological problems.

OBJECTIVES

The purposes of this study were to (1) explore the relationship between pain-related cognitions and psychological factors, CPM effects, and the central sensitization inventory (CSI) scores; and (2) determine whether cognitions and psychological factors can predict CSI scores and CPM effects in individuals with CNP.

METHODS

Fifty-four individuals with CNP were recruited for this cross-sectional study. The following outcome measures were evaluated: The CSI (screening tool) was compared with the cold pressor test (CPT), which was the psychophysical test used to assess the CPM; neck pain intensity using the visual analogue scale (VAS), as well as pain-related cognitions (including kinesiophobia and pain catastrophization) and psychological states (including anxiety and depression) using self-report questionnaires.

RESULTS

CSI score was not associated with the CPM effect (r = 0.257, p > 0.05), and no cognitions or psychological factors were associated with CPM (p > 0.05), but CSI score was moderately positively correlated with kinesiophobia (r = 0.554, p < 0.01), lowly positively correlated with pain catastrophization (r = 0.332, p = 0.017) and anxiety (r = 0.492, p < 0.01), but not depression (r = 0.207, p = 0.132). Multiple linear regression analysis showed that kinesiophobia (B = 1.308, p < 0.01) and anxiety (B = 1.806, p = 0.02) were significant positive predictors of CSI score.

CONCLUSIONS

The findings confirm some of our hypotheses. Accordingly, the findings inferred that the CSI does not seem to respond to CPM effect in patients with CNP effectively. In addition, CSI score was associated with cognitions and psychological factors, of which kinesiophobia and anxiety were effective predictors. In clinical practice, pain-related cognitions and psychological factors should be fully considered to manage neck pain efficiently.

The Effectiveness of Pain Science Education on Caregiver and Children's Knowledge, Beliefs, Attitudes, and Behaviors-A Systematic Review and Meta-Analysis

Pain science education (PSE) can be used as part of treatment and prevention for chronic pain in children. We assessed the effectiveness of PSE on knowledge, beliefs, attitudes, and behaviors in children and the people that care for children. We set a minimum criterion for education to address pain biology knowledge. We included studies aimed at both treatment and prevention of chronic pain. We conducted searches using 5 databases. We assessed the risk of bias using the Cochrane Risk of Bias 2 tool. Data were pooled using a random-effects meta-analysis or assessed using a narrative synthesis. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation. We screened 14,505 records and included 7 studies involving 351 caregivers and 1,285 children. Four studies were included in meta-analyses. We found low-certainty evidence that PSE has a large beneficial effect on caregiver knowledge and beliefs compared with alternative education (standardized mean difference = 1.14 [95% confidence interval: .88-1.42]; I2 = 0%). We found no difference in functional disability in children with chronic pain after PSE (Functional Disability Inventory score mean difference = .73 [95% confidence interval: -.81 to 2.27; I = 0%]). Narrative syntheses showed low-certainty evidence for improved knowledge and beliefs in children with preventative and treatment effects. Overall, we found few studies, and along with high risk of bias, this significantly contributed to the low certainty of findings. The effect of learning pain science for both preventative and treatment effects in children, carers, and the child/carer dyad remains mostly unknown. This review was prospectively registered with The international Prospective register of systematic reviews (CRD42022344382) on July 22, 2022. PERSPECTIVE: This review examines the effect of PSE on pain-related knowledge, beliefs, attitudes, and behaviors in children and the people that care for children (0-18). The findings contribute to knowledge about pain treatments and health promotion for caregivers and their children with and without chronic pain.

Predictors of improvement in community adolescents with chronic neck pain: A secondary analysis using different improvement criteria

BACKGROUND

Interventions based on pain neuroscience education and exercise have emerged as effective in the management of chronic neck pain in adolescents. No studies have explored factors that might be associated with recovery in adolescents with neck pain.

OBJECTIVE

To explore predictors of improvement after an intervention based on exercise and pain neuroscience education.

DESIGN

Secondary analysis of a randomized trial.

SETTING

Community.

PARTICIPANTS

127 community adolescents with neck pain.

INTERVENTIONS

Blended-learning intervention based on exercise and pain neuroscience education.

MAIN OUTCOME MEASURES

A set of variables including sociodemographic data, pain characteristics, physical activity, disability, sleep, catastrophizing, fear of movement, self-efficacy, symptoms of central sensitization, knowledge of pain neuroscience, pressure pain thresholds, and neck muscles endurance were used to predict a clinical response at 1 week after intervention and at 6-month follow-up.

RESULTS

Different predictors of improvement and non-improvement to intervention were found, but common predictors were not found for all the improvement criteria explored and time points.

CONCLUSIONS

These findings suggest that using different criteria to characterize adolescents with neck pain as improved and non-improved after pain neuroscience education and exercise have an effect on the variables associated with a response to the intervention.

Pain neuroscience education for reducing pain and kinesiophobia in patients with chronic neck pain: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Chronic neck pain (CNP) is a common musculoskeletal disorder. Pain neuroscience education (PNE) is a promising nonpharmacological intervention for CNP, however, its effectiveness remains unclear. This systematic review and meta-analysis aimed to evaluate the effectiveness of PNE in treating CNP.

METHODS

Electronic databases from inception to February 2023 were searched for randomized controlled trials (RCTs) on the effects of PNE on CNP. The primary outcome was the change in pain intensity, and the secondary outcome was improvement in kinesiophobia, standardized using Hedges' g. Two authors independently scrutinized eligible articles, extracted data and assessed quality; a random-effects model was employed for data pooling.

RESULTS

In total, seven RCTs comprising 479 participants were included and demonstrated that PNE significantly reduced pain intensity (Hedges' g = -0.730, 95% CI = -1.340 to -0.119, p = 0.019, I2  = 89.288%). Subgroup analysis revealed that the adult group experienced significant pain reduction after PNE, whereas the adolescent group did not. PNE also reduced kinesiophobia which was evaluated in four of seven RCTs (Hedges' g = -0.444, 95% CI = -0.735 to -0.154, p = 0.003, I2  = 36.822%). The meta-regression analysis indicated that an increased intervention duration contributed to greater pain reduction. No adverse events were reported following PNE or the control treatment.

CONCLUSIONS

PNE effectively reduced pain intensity and kinesiophobia in patients with CNP. A longer PNE time leads to greater pain reduction and is more effective in adults than in adolescents. Further studies are required to examine the long-term effects on CNP management.

SIGNIFICANCE

This is the first meta-analysis evaluating the effectiveness of treating chronic neck pain with pain neuroscience education. Pain neuroscience education is successful in reducing pain and decreasing kinesiophobia in the chronic neck pain population. Longer treatment time leads to greater pain reduction.

Physical therapist-led interventions based on the biopsychosocial model provide improvement in disability and pain for spinal disorders: A systematic review and meta-analysis

OBJECTIVE

To summarize the effects of physical therapist-led interventions based on the biopsychosocial (BPS) model in spinal disorders compared to interventions with no BPS model through a systematic review and meta-analysis of randomized-controlled trials. TYPE: Systematic review and meta-analysis.

LITERATURE SURVEY

We searched the Web of Science, CENTRAL, MEDLINE, PsycINFO, CINAHL, and PEDro up to October 27, 2022.

METHODOLOGY

Pain intensity and disability were primary outcomes and psychological factors were secondary outcomes in spinal disorders. The included intervention was physical therapist-led interventions based on the BPS model. The control group received no physiotherapy intervention for BPS. Pooled effects were analyzed as standardized mean differences (SMDs) and 95% confidence intervals (CIs), and the random-effects model was used for the meta-analysis. The subgroup analysis was divided into low back pain group and neck pain group. Another subgroup analysis was conducted only of the groups that had received training of the BPS model.

SYNTHESIS

Fifty-seven studies with 5471 participants met the inclusion criteria. For pain intensity, there was a statistically significant effect for the BPS model led by physical therapists in the short, medium, and long terms. The SMDs with 95% CIs were -0.44 (-0.62, -0.27), -0.24 (-0.37, -0.12), and -0.17 (-0.28, -0.06), respectively. Outcomes were clinically significant, except in the long term. For disability, there was a statistically significant effect in the short, medium, and long terms. The SMDs with 95% CIs were -0.48 (-0.69, -0.27), -0.44 (-0.64, -0.25), and -0.37 (-0.58, -0.15), respectively. All periods were clinically significant. The quality of the evidence was low for all of the main outcomes for all of the terms.

CONCLUSION

Physical therapist-led interventions based on the BPS model effectively improve pain intensity and disability in patients with spinal disorders based on low-quality evidence.

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.

An evaluation of a one-day pain science education event in a high school setting targeting pain related beliefs, knowledge, and behavioural intentions

BACKGROUND

Persistent pain is a common condition affecting one in four UK adults. Public understanding of pain is limited. Delivering pain education within schools may improve public understanding in the longer term.

OBJECTIVE

To evaluate the impact of a one-day Pain Science Education (PSE) event on sixth form/high school students' pain beliefs, knowledge and behavioural intention.

METHODS

Exploratory, single-site, mixed-methods, single-arm study involving secondary school students ≥16 years old attending a one-day PSE event. Outcome measures included the Pain Beliefs Questionnaire (PBQ), Concepts of Pain Inventory (COPI-ADULT), a vignette to assess pain behaviours; and thematic analysis of semi-structured interviews.

RESULTS

Ninety (mean age 16.5 years, 74% female) of the 114 attendees, agreed to participate in the evaluation. PBQ scores improved on the Organic beliefs subscale [mean difference -5.9 (95% CI -6.8, -5.0), P < 0.01] and Psychosocial Beliefs subscale [1.6 (1.0, 2.2) P < 0.01]. The COPI-Adult revealed an improvement [7.1 (6.0-8.1) points, P < 0.01] between baseline and post intervention. Pain behavioural intentions improved post education for work, exercise, and bed rest related activities (p < 0.05). Thematic analysis of interviews (n = 3) identified increased awareness of chronic pain and its underpinning biology, beliefs that pain education should be widely available, and that pain management should be holistic.

CONCLUSIONS

A one-day PSE public health event can improve pain beliefs, knowledge and behavioural intentions in high school students and increase openness to holistic management. Future controlled studies are needed to confirm these results and investigate potential long-term impacts.

Physical activity and education about physical activity for chronic musculoskeletal pain in children and adolescents

BACKGROUND

Chronic pain is a major health and socioeconomic burden, which is prevalent in children and adolescents. Among the most widely used interventions in children and adolescents are physical activity (including exercises) and education about physical activity.

OBJECTIVES

To evaluate the effectiveness of physical activity, education about physical activity, or both, compared with usual care (including waiting-list, and minimal interventions, such as advice, relaxation classes, or social group meetings) or active medical care in children and adolescents with chronic musculoskeletal pain.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PEDro, and LILACS from the date of their inception to October 2022. We also searched the reference lists of eligible papers, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared physical activity or education about physical activity, or both, with usual care (including waiting-list and minimal interventions) or active medical care, in children and adolescents with chronic musculoskeletal pain.

DATA COLLECTION AND ANALYSIS

Two review authors independently determined the eligibility of the included studies. Our primary outcomes were pain intensity, disability, and adverse events. Our secondary outcomes were depression, anxiety, fear avoidance, quality of life, physical activity level, and caregiver distress. We extracted data at postintervention assessment, and long-term follow-up. Two review authors independently assessed risk of bias for each study, using the RoB 1. We assessed the overall certainty of the evidence using the GRADE approach. We reported continuous outcomes as mean differences, and determined clinically important differences from the literature, or 10% of the scale.

MAIN RESULTS

We included four studies (243 participants with juvenile idiopathic arthritis). We judged all included studies to be at unclear risk of selection bias, performance bias, and detection bias, and at high risk of attrition bias. We downgraded the certainty of the evidence for each outcome to very low due to serious or very serious study limitations, inconsistency, and imprecision. Physical activity compared with usual care Physical activity may slightly reduce pain intensity (0 to 100 scale; 0 = no pain) compared with usual care at postintervention (standardised mean difference (SMD) -0.45, 95% confidence interval (CI) -0.82 to -0.08; 2 studies, 118 participants; recalculated as a mean difference (MD) -12.19, 95% CI -21.99 to -2.38; I² = 0%; very low-certainty evidence). Physical activity may slightly improve disability (0 to 3 scale; 0 = no disability) compared with usual care at postintervention assessment (MD -0.37, 95% CI -0.56 to -0.19; I² = 0%; 3 studies, 170 participants; very low-certainty evidence). We found no clear evidence of a difference in quality of life (QoL; 0 to 100 scale; lower scores = better QoL) between physical activity and usual care at postintervention assessment (SMD -0.46, 95% CI -1.27 to 0.35; 4 studies, 201 participants; very low-certainty evidence; recalculated as MD -6.30, 95% CI -18.23 to 5.64; I² = 91%). None of the included studies measured adverse events, depression, or anxiety for this comparison. Physical activity compared with active medical care We found no studies that could be analysed in this comparison. Education about physical activity compared with usual care or active medical care We found no studies that could be analysed in this comparison. Physical activity and education about physical activity compared with usual care or active medical care We found no studies that could be analysed in this comparison.

AUTHORS' CONCLUSIONS

We are unable to confidently state whether interventions based on physical activity and education about physical activity are more effective than usual care for children and adolescents with chronic musculoskeletal pain. We found very low-certainty evidence that physical activity may reduce pain intensity and improve disability postintervention compared with usual care, for children and adolescents with juvenile idiopathic arthritis. We did not find any studies reporting educational interventions; it remains unknown how these interventions influence the outcomes in children and adolescents with chronic musculoskeletal pain. Treatment decisions should consider the current best evidence, the professional's experience, and the young person's preferences. Further randomised controlled trials in other common chronic musculoskeletal pain conditions, with high methodological quality, large sample size, and long-term follow-up are urgently needed.