Short-term impact of combining pain neuroscience education with exercise for chronic musculoskeletal pain: a systematic review and meta-analysis

A multicenter feasibility randomized controlled trial using a virtual reality application of pain neuroscience education for adults with chronic low back pain

BACKGROUND

Chronic low back pain (CLBP) is a highly prevalent condition among adults and is correlated to high levels of pain, high disability, and lower quality of life. Pain neuroscience education (PNE) helps to explain the pain experience and can affect psychosocial factors, such as fear of movement, anxiety, socioeconomic status, work life satisfaction, etc. More recently, virtual reality (VR) programs have emerged allowing for immersive PNE experiences.

OBJECTIVE

The purpose of this randomized clinical trial is to determine the feasibility of using a VR application for the delivery of immersive PNE (VR-PNE) and other activity training for patients with CLBP presenting to outpatient physical therapy (PT) clinics.

METHODS

A two-arm, parallel group, randomized controlled feasibility trial of patients was conducted at 12 outpatient PT clinics from March 9, 2022, through September 9, 2022. The intervention group received PT as usual and VR-PNE while the control group received PT as usual. Between group feasibility, acceptability outcomes and other patient-reported outcomes were assessed at six weeks.

RESULTS

A total of 595 individuals were evaluated for low back pain during the recruitment period. Seventy individuals were eligible and met definition for CLBP, 52 enrolled and 32 completed the trial. Participant adherence was 63.6% for VR-PNE and 63.2% for PT as usual. Participants found VR-PNE acceptable and reported satisfaction scores (0-100) of 87.37 ± 11.05 compared to 81.17 ± 23.72 in the PT as usual group. There were no significant differences between groups for the BBQ, BRS, FABQ-PA, FABQ-W, GROC, NPRS, NPQ, PCS, and PSEQ at 6 weeks.

CONCLUSION

The results of the trial suggest that VR-PNE may be acceptable and feasible for patients with CLBP. Study procedures and PT delivery modifications should be considered for the next iteration of this study to improve follow-up assessment rates.

Italian versions of the Neurophysiology of Pain Questionnaire (NPQ): psychometric properties and an investigation on the understanding of pain neurophysiology in physical therapists

OBJECTIVES

The Neurophysiology of Pain Questionnaire (NPQ) is widely used to assess pain knowledge among clinicians and patients with pain, but an Italian version is not available. This study aimed to translate and cross-culturally adapt the NPQ into Italian, to test its psychometric properties, to assess the knowledge of Italian physical therapists (PTs) on pain, and to evaluate which characteristics are associated with pain knowledge.

METHODS

The NPQ was translated into Italian, integrated with some additional questions (IT-NPQ-New), and sent by email via the Italian Association of Physiotherapy newsletter. Rasch analysis (RA) was used to test the psychometric properties of the Italian versions. Multivariable regression analyses were used to check for associations between participants' characteristics and their NPQ scores.

RESULTS

A sample of 753 PTs completed the survey. RA of the NPQ-19 and IT-NPQ-New revealed that 10 (IT-NPQ-10) and 18 (IT-NPQ-18) items fit the model. Both questionnaires showed good psychometric properties. The overall median score among Italian PTs was 6.0 [5.0-7.0] and 11.0 [9.0-13.0] points for the IT-NPQ-10 and the IT-NPQ-18, respectively. These scores were statistically different among groups according to gender, age, years of professional activity, post-graduate specialization and days attended of targeted pain courses, with the latter being the most influential variable.

CONCLUSIONS

Italian PTs now dispose of two tools to assess their basic knowledge related to pain science. Our study also showed that pain knowledge among Italian PTs needs improvement, especially considering recent biopsychosocial approaches to pain.

Pain Neuroscience Education Following Arthroscopic Rotator Cuff Repair for Patients With Rotator Cuff Tears: A Double-Blind Randomized Controlled Clinical Trial

OBJECTIVE

This trial examines the efficacy of the pain neuroscience education on clinical outcomes in patients with arthroscopic rotator cuff repair.

DESIGN

A total of 36 participants undergoing arthroscopic rotator cuff repair were assigned to either the experimental group ( n = 18) or control group ( n = 18) in this randomized study. A 6-wk-long conventional physiotherapy program was administered for both groups. In addition, a pain neuroscience education protocol was administered for the experimental group for a whole period of 6 wks (1 session/week, 15-60 mins per session). The primary outcomes were to compare pretreatment and posttreatment scores of the experimental versus control groups on the pain and disability. Our secondary outcomes included the comparisons of scores on the catastrophizing, anxiety, depression, kinesiophobia, and quality of life. The participants were assessed both at baseline and posttreatment.

RESULTS

The improvement in pain catastrophizing, anxiety, depression, and kinesiophobia was greater in the experimental group ( P < 0.05). The improvement was similar in both groups in terms of the rest of outcome measures.

CONCLUSIONS

This study showed that the pain neuroscience education improved only psychological aspects of the chronic pain in arthroscopic rotator cuff repair. Therefore, adding pain neuroscience education to the conventional program might be useful to improve pain catastrophizing, anxiety, depression, and kinesiophobia in patients with arthroscopic rotator cuff repair.

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.

Assessing healthcare professionals' perceptions of pain concepts and beliefs

BACKGROUND

Healthcare professionals deliver pain education, yet their perception of pain experiences is not well understood, which can affect their interactions with patients in pain.

OBJECTIVE

This study explored Korean healthcare professionals' perceptions of the usefulness of assessing pain concepts and beliefs and the importance of domains identified in the pain literature.

METHODS

This descriptive cross-sectional study employed an online survey administered to nurses, physical therapists, and physicians, including the Neurophysiology of Pain Questionnaire, Tampa Scale for Kinesiophobia, and related optional open-ended questions.

RESULTS

Most participants acknowledged the importance and usefulness of assessing understanding of pain concepts but anticipated patients' difficulty comprehending items assessing biological mechanisms underlying pain. Participants questioned the items' accuracy, indicating their limited pain knowledge and the necessity of reducing literacy demands. The critical domains of pain education were learning about pain, external factors influencing pain, and pain as a form of protection.

CONCLUSION

Participants had suboptimal pain knowledge but emphasized decreasing literacy demands of pain neurophysiology items. Additionally, it is necessary to develop and implement a pain education program to improve pain-related knowledge and provide educational content for healthcare professionals encountering patients in pain.

Exercise as a promising alternative for sciatic nerve injury pain relief: a meta-analysis

Objective

The efficacy of drug therapies in managing neuropathic pain is constrained by their limited effectiveness and potential for adverse effects. In contrast, exercise has emerged as a promising alternative for pain relief. In this study, we conducted a systematic evaluation of the therapeutic impact of exercise on neuropathic pain resulting from sciatic nerve injury in rodent models.

Methods

The PubMed, Embase, and Web of Science databases were retrieved before April 2024. A series of studies regarding the effect of treadmill, swimming, wheel and other exercises on neuropathic pain induced by sciatic nerve injury in rats and mice were collected. Using predefined inclusion criteria, two researchers independently performed literature screening, data extraction, and methodological quality assessment utilizing SYRCLE's risk of bias tool for animal studies. Statistical analysis was conducted using RevMan 5.3 and STATA 12.0 analysis software.

Results

A total of 12 relevant academic sources were included in the analysis of controlled animal studies, with 133 rodents in the exercise group and 135 rodents in the sedentary group. The meta-analysis revealed that exercise was associated with a significant increase in paw withdrawal mechanical threshold [Standard Mean Difference (SMD) = 0.84, 95% confidence interval (CI): 0.28-1.40, p = 0.003] and paw withdrawal thermal latency (SMD = 1.54, 95%CI: 0.93-2.15, p < 0.0001) in rats and mice with sciatic nerve injury. Subgroup analyses were conducted to evaluate the impact of exercise duration on heterogeneity. The results showed that postoperative exercise duration ≤3 weeks could significantly elevate paw withdrawal mechanical threshold (SMD = 1.04, 95% CI: 0.62-1.46, p < 0.00001). Postoperative exercise duration ≤4 weeks could significantly improve paw withdrawal thermal latency (SMD = 1.93, 95% CI:1.19-2.67, p < 0.00001).

Conclusion

Exercise represents an effective method for improving mechanical and thermal hypersensitivity resulting from sciatic nerve injury in rodents. Factors such as pain models, the initiation of exercise, the type of exercise, and the species of rodent do not significantly impact the development of exercise-induced hypoalgesia. However, the duration of postoperative exercise plays a crucial role in the onset of exercise-induced hypoalgesia.

Meaningful contributions of rehabilitation for people with persistent pain; a reflexive thematic analysis

PURPOSE

This study aims to explore the meaningful contributions of rehabilitation for participants living with persistent pain.

MATERIALS AND METHODS

A phenomenological methodology was used. Thirteen purposefully selected participants, who self-identified as substantially improved from persistent pain due to rehabilitation, were interviewed in-depth. Data were analyzed using reflexive thematic analyses.

RESULTS

Participants included three men and ten women, age ranging from 22-69 years, pain duration was 2-30 years. Seven interconnected themes were developed: 1) indication of negative pain and health care experiences, 2) supporting working alliance with healthcare professionals, 3) Pain Dialogue, 4) improved self-awareness and self-regulation, 5) different view on pain, 6) autonomy and personal growth and 7) hope and new perspective. Integration of these themes provided a framework for understanding meaningful contributions of rehabilitation from the participants' perspective.

CONCLUSIONS

The study identified seven interconnected themes enhancing meaningful contributions of rehabilitation for participants who have substantially improved from persistent pain. These findings provide a novel conceptual understanding of how rehabilitation can foster recovery. The themes strongly support person-centred care, an understanding of Pain Dialogue and personal growth through the lens of the lived experience. The quality of the therapeutic relationship is considered a central vehicle for improved health outcomes.

Effectiveness of Hybrid Form Impulse Therapy (HFIT) Compared to Traditional Transcutaneous Electronic Nerve Stimulation (TENS) in Patients with Chronic Low Back and Knee Pain: A Randomized Controlled Trial

Purpose

Physical therapy (PT) and conservative care are recommended first-line treatments for musculoskeletal (MSK) pain. While essential to high-quality care, these solutions often do not provide immediate or sufficient pain relief. Traditional transcutaneous electronic nerve stimulation (TENS) devices are often recommended; however, there is mixed evidence behind their effectiveness. A novel approach called hybrid form impulse therapy (HFIT) incorporates a priming pulse with a traditional TENS pulse width and frequency. This randomized controlled trial (RCT) aimed to compare the effectiveness of HFIT versus traditional TENS versus usual care among members of a digital MSK program.

Patients and Methods

A three-arm RCT comparing HFIT versus TENS versus usual care was conducted. A total of 325 people with chronic back or knee pain who were members of a digital MSK program consisting of PT-guided exercise therapy, education, and coaching were randomized. Outcomes including pain, function, anxiety, and depression were examined at 1, 2, and 4 weeks (primary endpoint). Engagement was measured through exercise therapy (ET) sessions completed. Unadjusted and adjusted logistic generalized estimating equations were conducted.

Results

Adjusted per-protocol results at 4 weeks showed significantly lower odds of achieving pain improvement for both TENS (OR: 0.42, 95% CI: [0.19, 0.92]) and usual care (OR: 0.35, 95% CI: [0.17, 0.72]) groups, compared to HFIT group. Both HFIT and usual care users had significantly higher engagement than the TENS users (p=0.026 and p=0.002, respectively). No adverse events were reported throughout the study.

Conclusion

More participants of a digital MSK program who were randomized to the HFIT group experienced meaningful pain improvement at 4 weeks than participants who used TENS and usual care. HFIT can be an effective, non-pharmaceutical solution for relief as a complement to first-line treatments for patients with chronic back and knee pain.

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.

The effectiveness of peer support interventions for community-dwelling adults with chronic musculoskeletal pain: a systematic review and meta-analysis of randomised trials

ABSTRACT

This systematic review and meta-analysis critically examined the evidence for peer support interventions to reduce pain and improve health outcomes in community-dwelling adults with chronic musculoskeletal pain (PROSPERO CRD42022356850). A systematic search (inception-January 2023) of electronic databases and grey literature was undertaken to identify relevant randomised controlled trials, with risk of bias and GRADE assessments performed on included studies. Meta-analyses used a generic, inverse-variance, random-effects model, calculating mean difference (MD) or standardised mean difference (SMD). Of 16,445 records identified, 29 records reporting on 24 studies (n = 6202 participants) were included. All evidence had unclear/high risk of bias and low-very low certainty. Peer support interventions resulted in small improvements in pain (medium-term: MD -3.48, 95% CI -6.61, -0.35; long-term: MD -1.97, 95% CI -3.53, -0.42), self-efficacy (medium-term: SMD 0.26, 95% CI 0.16, 0.36; long-term: SMD 0.21, 95% CI 0.07, 0.36), and function (long-term: SMD -0.10, 95% CI -0.19, -0.00) relative to usual care and greater self-efficacy (medium-term: SMD 0.36, 95% CI 0.20, 0.51) relative to waitlist control. Peer support interventions resulted in similar improvement as active (health professional led) interventions bar long-term self-efficacy (MD -0.41, 95% CI -0.77, -0.05), which favoured active interventions. No point estimates reached minimal clinically important difference thresholds. Pooled health service utilisation outcomes showed unclear estimates. Self-management, quality of life, and social support outcomes had mixed evidence. Despite low-very low evidence certainty, peer support interventions demonstrated small improvements over usual care and waitlist controls for some clinical outcomes, suggesting that peer support may be useful as an adjunct to other treatments for musculoskeletal pain.

Role of physical therapy in adult chronic non-bacterial osteitis: patients' and therapists' perspectives

OBJECTIVES

Chronic nonbacterial osteitis (CNO) is a rare bone disease causing pain and functional impairment. We aimed to explore the application of physical therapy (PT) for adult CNO from the patients' and primary care therapists' perspective.

METHOD

Cross-sectional study among the Dutch adult CNO cohort (1992-present). A survey on PT-use for axial spondylarthritis was adapted for CNO. Patients using PT in the past 2 years (recent PT-users) were asked about modalities, perceived effects, satisfaction, and preferences for provision. Their current physical therapists were invited to complete a self-developed survey covering therapy details and educational preferences.

RESULTS

80/199 invited patients and 14/16 invited therapists completed the survey respectively. 41 (51%) patients used PT for CNO in the preceding 2 years, 14 (18%) used PT >2 years back, and 25 (31%) never used PT. Recent PT-users (n=41) reported diverse treatment modalities, involving massage (61%), joint mobilizations (44%), breathing exercises (49%), muscle strengthening (32%) and counselling through of home-exercises (46%) and pain education (32%). 64% of all patients desired greater emphasis from physicians regarding the role of PT. Most therapists would appreciate referral letters with CNO-specific information (93%), and consultations with specialized therapists (86%).

CONCLUSIONS

In this study, two-third of adult CNO patients had -ever or recently- used PT, which involved variable therapeutic modalities. Most patients were receptive to a larger role of PT in CNO-management and most therapists preferred CNO-specific information to optimize their care. These findings provide a foundation for the development and systematic evaluation of CNO-specific PT.

Efficacy of manual therapy on shoulder pain and function in patients with rotator cuff injury: A systematic review and meta‑analysis

To critically evaluate the effects of manual therapy (MT) on pain and functional improvement in patients with rotator cuff injury (RCI), a systematic review of all randomized controlled trials (RCTs) on MT for RCI was conducted in the following databases: PubMed, Cochrane Central Register of Controlled Trials, Embase, Web of Science, Physiotherapy Evidence Database, Chinese National Knowledge Infrastructure, Wan-fang Data, Chinese Scientific Journal Database, and Chinese Biomedical Literature database from inception to March 28, 2023. A total of 1,110 participants from 24 eligible RCTs were included in the analysis. Compared with placebo, MT could not effectively relieve pain [standardized mean difference (SMD)=-0.25; 95% CI: -0.51 to 0.01; P=0.06], although its impact on functional improvement appears limited (SMD=0.20; 95% CI: -0.09 to 0.49; P=0.18). Combining MT with exercise had significant advantages over exercise alone, as combined therapy contributed to both pain reduction (SMD=0.36; 95% CI: 0.08 to 0.64; P=0.01) and functional enhancement (SMD=0.32; 95% CI: 0.11 to 0.52; P=0.002). Furthermore, MT combined with multimodal physiotherapy showed additional benefits in pain reduction (mean difference=1.57; 95% CI: 0.18 to 2.96; P=0.03) and functional improvement (SMD=0.77; 95% CI: 0.43 to 1.12; P<0.0001) compared with multimodal physiotherapy alone. These findings highlight the superior pain alleviation and functional improvement provided by MT when combined with exercise or physiotherapy. Consequently, MT has emerged as a pivotal component of therapeutic intervention for RCI.

How do people with chronic low back pain perceive specific and general exercise? A mixed methods survey

PURPOSE

Exercise prescriptions for chronic low back pain (CLBP) often utilize reductionistic, trunk-focused exercise aimed at addressing proposed pain mechanisms. It is unknown if the use of these trunk-focused exercises imply beliefs to people with CLBP about the rationale for their use (e.g., etiology), even without concurrent biomedical narratives. This study aimed to explore people's perceptions of specific and general exercise without an accompanying narrative when experiencing CLBP.

METHODS

An anonymous online survey was distributed. Mixed methods were utilized for analysis. Six-point Likert scales categorized people's beliefs about individual exercises. Open-ended questions were used to gather further beliefs which were then coded into themes.

RESULTS

People with CLBP perceived specific exercise as more beneficial than general exercise. Eight themes and five subthemes were defined. A high volume of positive beliefs were centered around strengthening the low back and abdominal musculature, emphasizing the importance of correct technique. Negative beliefs were held against spinal flexion and external load. Both positive and negative beliefs were underpinned by spinal/pelvic stability being important as well as certain exercises being achievable or not.

CONCLUSION

This study demonstrated that people with CLBP consider specific exercises to be more beneficial than general exercises for CLBP. Specific exercises irrespective of an accompanying narrative can imply meaning about the intent of an exercise. Understanding this requires practitioners to be mindful when prescribing and communicating exercise.

Gray Matter Adaptations to Chronic Pain in People with Whiplash-Associated Disorders are Partially Reversed After Treatment: A Voxel-based Morphometry Study

Gray matter (GM) changes are often observed in people with chronic spinal pain, including those with chronic whiplash-associated disorders (CWAD). These GM adaptations may be reversed with treatment, at least partially. Pain neuroscience education combined with exercise (PNE+Exercise) is an effective treatment, but its neural underlying mechanisms still remain unexplored in CWAD. Here, we performed both cross-sectional and longitudinal voxel-based morphometry to 1) identify potential GM alterations in people with CWAD (n = 63) compared to age- and sex-matched pain-free controls (n = 32), and 2) determine whether these GM alterations might be reversed following PNE+Exercise (compared to conventional physiotherapy). The cross-sectional whole-brain analysis revealed that individuals with CWAD had less GM volume in the right and left dorsolateral prefrontal cortex and left inferior temporal gyrus which was, in turn, associated with higher pain vigilance. Fifty individuals with CWAD and 29 pain-free controls were retained in the longitudinal analysis. GM in the right dorsolateral prefrontal cortex increased after treatment in people with CWAD. Moreover, the longitudinal whole-brain analysis revealed that individuals with CWAD had decreases in GM volumes of the left and right central operculum and supramarginal after treatment. These changes were not specific to treatment modality and some were not observed in pain-free controls over time. Herewith, we provide the first evidence on how GM adaptations to CWAD respond to treatment. PERSPECTIVE: This article presents which gray matter adaptations are present in people with chronic pain after whiplash injuries. Then, we examine the treatment effect on these alterations as well as whether other neuroplastic effects on GM following treatment occur.

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.

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.

Questionnaires assessing knowledge and beliefs about musculoskeletal conditions are potentially suitable for use, but further research is needed: a systematic review

OBJECTIVES

To evaluate the measurement properties of Patient-reported outcome measures (PROMs) for knowledge and/or beliefs about musculoskeletal conditions.

STUDY DESIGN AND SETTING

A systematic review was performed according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines. This review was prospectively registered on PROSPERO - ID: CRD42022303111. Electronic databases, reference lists, forward citation tracking, and contact with experts were used to identify studies. Eligible studies were reports developing or assessing a measurement property of a PROM measuring musculoskeletal condition specific-knowledge and/or beliefs. We assessed the methodological quality and measurement properties of included studies. A modified Grading of Recommendations Assessment Development and Evaluation approach was used to rate the quality of evidence for each PROM.

RESULTS

The literature search was performed from inception to 11th September 2023. Sixty records were included, reporting 290 individual studies, and provided information on 25 PROMs. Five PROMs presented sufficient structural validity, three presented sufficient cross-cultural validity, ten presented sufficient reliability, three presented sufficient criterion validity, six presented sufficient hypothesis-testing, and four presented sufficient responsiveness. No PROM presented sufficient evidence for content validity, internal consistency, and measurement error. Based on the available evidence, no PROM was classified as suitable for use according to the COSMIN recommendations. Twenty-four PROMs are potentially suitable for use, and one PROM is not recommended for use.

CONCLUSION

No PROM designed to assess knowledge and/or beliefs about musculoskeletal conditions meets the COSMIN criteria of suitable for use. Most PROMs identified in this systematic review were considered as potentially suitable for use and need further high-quality research to assess their measurement properties.

Physical activity should be the primary intervention for individuals living with chronic pain A position paper from the European Pain Federation (EFIC) 'On the Move' Task Force

BACKGROUND

There is clear evidence demonstrating the benefits of physical activity (PA) on pain and overall health, however, PA is challenging for many individuals living with chronic pain. Even non-exercise specialists can (cost) effectively promote PA, but many health professionals report a number of barriers in providing guidance on PA, suggesting that it is not consistently promoted. This expert position paper summarizes the evidence and provides five recommendations for health professionals to assess, advise and support individuals living with any chronic pain condition with a long life expectancy in adopting and sustaining physically active lifestyles.

METHODS

This position paper was prepared by the 'On The Move' Task Force of the European Pain Federation EFIC. Final recommendations were endorsed by the European Pain Forum, Pain Alliance Europe and the Executive Board of EFIC.

RESULTS

We recommend that all health professionals (1) Take a history of the persons' PA levels, and put PA on the agenda, (2) Advise that PA is important and safe for individuals living with chronic pain, (3) Deliver a brief PA intervention and support individuals living with chronic pain in becoming physically active, (4) Discuss acceptable levels of PA-related soreness and pain and (5) Provide ongoing support in staying physically active.

SIGNIFICANCE

Physical activity is safe and offers several advantages, including general health benefits, low risk of side effects, low cost and not requiring access to healthcare. Adoption of these recommendations can improve the quality of care and life of individuals living with chronic pain and reduce their overall health risks.

Effects of Pain Neuroscience Education and Physiotherapy on Chronic Low Back Pain, Fear of Movement and Functional Status: A Randomised Pilot Study

Background: Chronic non-specific low back pain is a non-harmous condition often found in the general population. It is one of the most significant disabilities and needs different treatment modalities. This study investigates the effects of pain neuroscience education and physiotherapy on pain intensity, fear of movement and functional status in a Lithuanian cohort with non-specific low back pain. Methods: The study was performed at the primary health care unit in Kaunas, Lithuania. The key inclusion criterion was persistent non-specific low back pain longer than three months and which affects daily life functions. Thirty participants (mean 33.47, SD 4.38 years age, 70% women) were randomised into two training groups with and without pain neuroscience education (for a total of 60 min of teaching). Physiotherapy was performed twice per week during 45 min/session for a period of 10 weeks with exercises which strengthen, stabilize, and stretch the spinal cord muscles. Outcomes included pain intensity, kinesiophobia and disability and these were measured by self-scored questionnaires (numeric rating scale, Tampa scale for kinesiophobia-11, Oswestry disability index and the Roland-Morris questionnaire, respectively). Results: The results indicate that both groups improved in the measured outcomes, with the only difference between them being a better improvement in kinesiophobia in the group receiving physiotherapy and pain neuroscience education. Conclusions: The results of this study confirm that a relatively short intervention of pain neuroscience education enhances the effects of physiotherapy and should be implemented in clinical practice.

We Are All in This Together-Whole of Community Pain Science Education Campaigns to Promote Better Management of Persistent Pain

Persistent pain is a major public health issue-estimated to affect a quarter of the world's population. Public understanding of persistent pain is based on outdated biomedical models, laden with misconceptions that are contrary to best evidence. This understanding is a barrier to effective pain management. Thus, there have been calls for public health-based interventions to address these misconceptions. Previous pain-focussed public education campaigns have targeted pain beliefs and behaviours that are thought to promote recovery, such as staying active. However, prevailing pain-related misconceptions render many of these approaches counter-intuitive, at best. Pain Science Education improves understanding of 'how pain works' and has been demonstrated to improve pain and disability outcomes. Extending Pain Science Education beyond the clinic to the wider community seems warranted. Learning from previous back pain-focussed and other public health educational campaigns could optimise the potential benefit of such a Pain Science Education campaign. Pain Science Education-grounded campaigns have been delivered in Australia and the UK and show promise, but robust evaluations are needed before any firm conclusions on their population impact can be made. Several challenges exist going forward. Not least is the need to ensure all stakeholders are involved in the development and implementation of Pain Science Education public messaging campaigns. Furthermore, it is crucial that campaigns are undertaken through a health equity lens, incorporating underrepresented communities to ensure that any intervention does not widen existing health inequalities associated with persistent pain. PERSPECTIVE: Public misconceptions about pain are a significant public health challenge and a viable intervention target to reduce the personal, social, and economic burden of persistent pain. Adaptation of Pain Science Education, which improves misconceptions in a clinical setting, into the public health setting seems a promising approach to explore.

Association Between Pain Coping and Symptoms of Anxiety and Depression, and Work Absenteeism in People With Upper Limb Musculoskeletal Disorders: A Systematic Review and Meta-analysis

OBJECTIVE

To determine the prospective association of pain coping strategies and symptoms of anxiety and depression with work absenteeism in people with upper limb musculoskeletal disorders.

DATA SOURCES

A systematic search of PubMed, Web of Science, Embase, Cochrane Library, and Scopus databases was conducted from inception to September 23, 2022.

STUDY SELECTION

Prospective observational studies of adults with upper limb musculoskeletal disorders were included. Included studies had to provide data on the association of pain coping strategies (catastrophizing, kinesiophobia, self-efficacy or fear avoidance) or symptoms of anxiety and depression with work absenteeism.

DATA EXTRACTION

Study selection, data extraction, and assessment of methodological quality (Newcastle Ottawa Scale) were performed by 2 independent authors. Random-effects models were used for quantitative synthesis.

DATA SYNTHESIS

Eighteen studies (n=12,393 participants) were included. Most studies (77.8%) reported at least 1 significant association between 1 or more exposure factors (pain coping strategies or symptoms of anxiety and depression) and work absenteeism. Meta-analyses showed a statistically significant correlation between the exposure factors of catastrophizing (r=0.28, 95% confidence interval [CI]: 0.15 to 0.40; P<.0001) and symptoms of anxiety and depression (r=0.23, 95% CI: 0.10 to 0.34; P=.0003) with work absenteeism. The correlation between self-efficacy and work absenteeism was non-significant (r=0.24, 95% CI: -0.02 to 0.47; P=.0747).

CONCLUSIONS

Rehabilitation teams should consider assessing catastrophizing and symptoms of anxiety and depression to identify patients at risk for work absenteeism. Addressing these variables may also be considered in return-to-work programs for individuals with upper limb disorders.

The Impact of Exercise Prescription Variables on Intervention Outcomes in Musculoskeletal Pain: An Umbrella Review of Systematic Reviews

BACKGROUND

Musculoskeletal pain conditions are the largest contributors to disability and healthcare burden globally. Exercise interventions improve physical function and quality of life in individuals with musculoskeletal pain, yet optimal exercise prescription variables (e.g. duration, frequency, intensity) are unclear.

OBJECTIVE

We aimed to examine evidence gaps, methodological quality and exercise prescription recommendations in systematic reviews of exercise for musculoskeletal pain.

METHODS

In our prospectively registered umbrella review, PubMed, SPORTDiscus, Cochrane Database of Systematic Reviews, EMBASE, and CINAHL were searched from inception to 14 February 2023. Backward citation tracking was performed. We included peer-reviewed, English language, systematic reviews and meta-analyses of randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that compared exercise with conservative treatment, placebo or other exercise interventions in adults with musculoskeletal pain. Data were extracted from the following groups of reviews based on their reporting of exercise prescription data and analysis of the relationship between prescription variables and outcomes: (1) those that did not report any exercise prescription data, (2) those that reported exercise prescription data but did not perform a quantitative analysis and (3) those that performed a quantitative analysis of the relationship between exercise prescription variables and outcomes. Outcome measures were physical function, pain, mental health, adverse effects and adherence to treatment. AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews) was used to assess methodological quality.

RESULTS

From 6757 records, 274 systematic reviews were included. 6.6% of reviews did not report any exercise prescription data, and only 10.9% quantitatively analyzed the relationship between prescription variables and the outcome(s). The overall methodological quality was critically low in 85% of reviews.

CONCLUSION

High methodological quality evidence is lacking for optimal exercise training prescription variables in individuals with musculoskeletal pain. To better inform practice and evidence gaps, future systematic reviews should (1) identify optimum exercise prescription variables, for example, via dose-response (network) meta-analysis, (2) perform high-quality reviews per AMSTAR-2 criteria and (3) include outcomes of mental health, adverse events and exercise adherence.

PROSPERO REGISTRATION NUMBER

CRD42021287440 ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021287440 ).

The effectiveness of telerehabilitation-based exercise combined with pain neuroscience education for patients with facet joint arthrosis: A randomized controlled study

OBJECTIVES

This study aimed to investigate the short-term effectiveness of exercise combined with PNE and exercise alone via telerehabilitation for patients with low back pain (LBP) caused by facet joint arthrosis (FJA).

METHODS

This is a prospective, single-blind, randomized-controlled clinical trial. Forty-five patients with LBP caused by FJA were randomly allocated into three groups. The exercise (n = 15) and the exercise with PNE (n = 15) groups were provided interventions twice a week for six weeks via telerehabilitation. The control group (n = 15) was placed on the waiting list. The primary outcome measures were the numeric pain-rating scale (NPRS) at rest and with activity, The Oswestry disability index (ODI), the pain beliefs questionnaire (PBQ), and secondary outcome measures were short form-12v2 (SF-12v2) and the global rating of change score (GROC).

RESULTS

The groups (52.00 ± 4.86, 46.7% female) were similar at baseline except for gender (p = 0.029). There was a significant group-by-time interaction for NPRS-rest (F = 4.276, p = 0.021), NPRS-activity (F = 12.327, p = 0.0001), the ODI (F = 23.122, p = 0.0001) and organic pain belief (F = 39.708, p = 0.0001). Further comparison with ANOVA showed that the exercise with PNE group showed better improvement in only organic pain belief (p = 0.0001). All groups reported improvements according to GROC, but it was higher in the intervention groups (p = 0.001).

CONCLUSION

The patients who received exercise combined with PNE and exercise alone significantly improved pain intensity, disability and organic pain beliefs via telerehabilitation for patients with LBP caused by FJA compared to the control group. The PNE in addition to exercise may exhibit greater benefit in improving organic pain beliefs in short term.

SIGNIFICANCE

This study highlights that combining exercise with PNE can lead to greater improvements compared to exercise alone or no intervention for FJA patients. The implementation of PNE in physiotherapy sessions has the potential to offer significant benefits. Furthermore, our results highlight the promising role of telerehabilitation as an effective method for delivering interventions to individuals with FJA.

High pain reported at 3 months post-total knee arthroplasty often persists for the next 3 years and is associated with reduced function and quality of life

BACKGROUND AND AIMS

Five to ten percent of people having a knee arthroplasty for osteoarthritis continue to experience high pain levels more than 3 months after surgery. The primary aim of this study was to determine the relative risk (RR) of having high pain at 12 and 36 months based on the presence of high pain at 3 and 12 months, respectively.

METHODS

A retrospective analysis of data from a prospective study of participants who had a total knee arthroplasty for osteoarthritis. A score of ≤14 on the Oxford Knee Pain Subscale was defined as 'High Pain', and RRs were calculated comparing those with high or low pain.

RESULTS

There were 718 participants and 13.8% reported high pain at any time point, 2.5% reported high pain at all time points and 10.3% and 4.7% and 6.6% reported high pain at 3-, 12- and 36-months, respectively, post-surgery. For participants with high pain at 3 months, 33.8% had high pain at 12 months with a RR of 24.2 (95% CI 11.7-49.8, p < 0.001) and 35.1% had high pain at 36 months with a RR of 10.8 (95% CI 6.4-18.2, p < 0.001). For participants with high pain at 12 months, 67.6% had high pain at 36 months, with a RR of 19.3 (95% CI 12.2-30.4, p < 0.01).

CONCLUSIONS

Although high pain rates are low overall following knee arthroplasty, once high pain is established there is an elevated RR of it persisting at 12- and 36 months post-surgery.

TRIAL REGISTRATION

The data were collected in the Evidence-based Processes and Outcomes of Care (EPOC) study, ClinicalTrials.gov Identifier: NCT01899443.

Association between the Number of Days/Week of Different Levels of Physical Activity and Chronic Pain in People of Different Races: A Mendelian Randomization Study

OBJECTIVE

Regular physical activity is beneficial for health, but the effect of the number of days/week of physical activity on chronic pain (CP) remains unclear, so we used a two-sample Mendelian randomization (MR) analysis to explore the relationship between the number of days/weeks of different levels of physical activity and chronic pain in people of different races.

METHODS

We obtained summary data from genome-wide association studies (GWASs) on the number of days/week of physical activity and multisite chronic pain in European, South Asian, East Asian, Middle Eastern, and African American populations. The single-nucleotide polymorphisms (SNPs) of the exposed data were visualized with a Manhattan plot via the R program. MR analysis was performed by the MR-Base platform.

RESULTS

The results indicated that a higher number of days/week with ≥10 min of walking protects against CP in African American and Afro-Caribbean populations (inverse-variance weighting, IVW p < 0.05) but has little effect on people of different races (IVW p > 0.05). A higher number of days/week with ≥10 min of moderate physical activity increased the risk of CP in European and South Asia (IVW p < 0.05) but had little effect on people of different races (IVW p > 0.05). The number of days/week of ≥10 min of vigorous physical activity increased the risk of CP in Europeans (IVW p < 0.05) and protected against CP in African Americans and Afro-Caribbeans (IVW p < 0.05).

CONCLUSIONS

A higher number of days/week of moderate and vigorous physical activity increased the risk of CP in Europeans; however, a higher number of days/week of walking and vigorous physical activity may protect against CP in African American and Afro-Caribbean individuals.

Specific Neurodynamic Exercises on Pain and Disability in Old Women with Chronic Mechanical Neck Pain: A Randomized Controlled Trial

Neurodynamic exercise is a specific type of exercise used as a neural treatment that focuses on restoring altered homeostasis in the neuroimmune system by mobilising the nervous system and other structures. A prospective, randomized clinical trial was performed to evaluate the effect of neurodynamic exercises on disability and neck pain in elderly women over four weeks. Participants were randomized into two groups: a neurodynamic (NM) group (n = 28) and a non-specific exercise (NSE) group (n = 28). Inclusion criteria were women over 65 years of age who subjectively admitted to having mechanical neck pain for more than six months. Results showed that specific neurodynamic exercises can improve pain and disability in older women with chronic mechanical neck pain. Improvements were observed in all variables (p < 0.05). Significant between-group differences in favour of the NM group were only found for neck pressure pain thresholds and both tibialis anterior muscles. Larger effect sizes were obtained in favour of the NM group, especially for pain, disability, neck extension and inclination and pressure pain thresholds. Neurodynamic exercises have been shown to be more clinically relevant in disability and neck pain in older women.

Acceptability of a Pain History Assessment and Education Chatbot (Dolores) Across Age Groups in Populations With Chronic Pain: Development and Pilot Testing

BACKGROUND

The delivery of education on pain neuroscience and the evidence for different treatment approaches has become a key component of contemporary persistent pain management. Chatbots, or more formally conversation agents, are increasingly being used in health care settings due to their versatility in providing interactive and individualized approaches to both capture and deliver information. Research focused on the acceptability of diverse chatbot formats can assist in developing a better understanding of the educational needs of target populations.

OBJECTIVE

This study aims to detail the development and initial pilot testing of a multimodality pain education chatbot (Dolores) that can be used across different age groups and investigate whether acceptability and feedback were comparable across age groups following pilot testing.

METHODS

Following an initial design phase involving software engineers (n=2) and expert clinicians (n=6), a total of 60 individuals with chronic pain who attended an outpatient clinic at 1 of 2 pain centers in Australia were recruited for pilot testing. The 60 individuals consisted of 20 (33%) adolescents (aged 10-18 years), 20 (33%) young adults (aged 19-35 years), and 20 (33%) adults (aged >35 years) with persistent pain. Participants spent 20 to 30 minutes completing interactive chatbot activities that enabled the Dolores app to gather a pain history and provide education about pain and pain treatments. After the chatbot activities, participants completed a custom-made feedback questionnaire measuring the acceptability constructs pertaining to health education chatbots. To determine the effect of age group on the acceptability ratings and feedback provided, a series of binomial logistic regression models and cumulative odds ordinal logistic regression models with proportional odds were generated.

RESULTS

Overall, acceptability was high for the following constructs: engagement, perceived value, usability, accuracy, responsiveness, adoption intention, esthetics, and overall quality. The effect of age group on all acceptability ratings was small and not statistically significant. An analysis of open-ended question responses revealed that major frustrations with the app were related to Dolores' speech, which was explored further through a comparative analysis. With respect to providing negative feedback about Dolores' speech, a logistic regression model showed that the effect of age group was statistically significant (χ22=11.7; P=.003) and explained 27.1% of the variance (Nagelkerke R2). Adults and young adults were less likely to comment on Dolores' speech compared with adolescent participants (odds ratio 0.20, 95% CI 0.05-0.84 and odds ratio 0.05, 95% CI 0.01-0.43, respectively). Comments were related to both speech rate (too slow) and quality (unpleasant and robotic).

CONCLUSIONS

This study provides support for the acceptability of pain history and education chatbots across different age groups. Chatbot acceptability for adolescent cohorts may be improved by enabling the self-selection of speech characteristics such as rate and personable tone.

Reductions in kinesiophobia and distress after pain neuroscience education and exercise lead to favourable outcomes: a secondary mediation analysis of a randomized controlled trial in primary care

ABSTRACT

Pain neuroscience education combined with exercise (PNE + exercise) is an effective treatment for patients with chronic spinal pain. Yet, however, little is known about its underlying therapeutic mechanisms. Thus, this study aimed to provide the first insights by performing a novel mediation analysis approach in a published randomized controlled trial in primary care where PNE + exercise was compared with standard physiotherapy. Four mediators (catastrophizing, kinesiophobia, central sensitization-related distress, and pain intensity) measured at postintervention and 3 outcomes (disability, health-related quality of life, and pain medication intake) measured at 6-month follow-up were included into the analysis. The postintervention measure of each outcome was also introduced as a competing candidate mediator in each respective model. In addition, we repeated the analysis by including all pairwise mediator-mediator interactions to allow the effect of each mediator to differ based on the other mediators' values. Postintervention improvements in disability, medication intake, and health-related quality of life strongly mediated PNE + exercise effects on each of these outcomes at 6-month follow-up, respectively. Reductions in disability and medication intake were also mediated by reductions in kinesiophobia and central sensitization-related distress. Reductions in kinesiophobia also mediated gains in the quality of life. Changes in catastrophizing and pain intensity did not mediate improvements in any outcome. The mediation analyses with mediator-mediator interactions suggested a potential effect modification rather than causal independence among the mediators. The current results, therefore, support the PNE framework to some extent as well as highlight the need for implementing the recent approaches for mediation analysis to accommodate dependencies among the mediators.

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

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

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.

Nonpharmacological approaches for pain and symptoms of depression in people with osteoarthritis: systematic review and meta-analyses

People with osteoarthritis often experience pain and depression. These meta-analyses examined and compared nonpharmacological randomized controlled trials (RCTs) for pain and symptoms of depression in people living with osteoarthritis. RCTs published up until April 2022 were sourced by searching electronic databases EMBASE, PUBMED & MEDLINE, Web of Science, CINAHL and PEDro. Random-effects meta-analyses were performed to calculate pooled effect sizes (ES) and 95% confidence intervals (CI) for pain and depression. Subgroup analyses examined intervention subtypes. For pain, 29 interventions (n = 4382; 65 ± 6.9 years; 70% female), revealed a significant effect on reducing pain (ES = 0.43, 95% CI [0.25, 0.61], p < 0.001). Effect sizes were significant (p < 0.001) for movement meditation (ES = 0.52; 95% CI [0.35, 0.69]), multimodal approaches (ES = 0.37; 95% CI [0.22, 0.51]), and psychological therapy (ES = 0.21; 95% CI [0.11, 0.31]), and significant (p = 0.046) for resistance exercise (ES = 0.43, 95% CI [- 0.07, 0.94]. Aerobic exercise alone did not improve pain. For depression, 28 interventions (n = 3377; 63 ± 7.0 years; 69% female), revealed a significant effect on reducing depressive symptoms (ES = 0.29, 95% CI [0.08, 0.49], p < 0.001). Effect sizes were significant for movement meditation (ES = 0.30; 95% CI [0.06, 0.55], p = 0.008) and multimodal interventions (ES = 0.12; 95% CI [0.07, 0.18], p < 0.001). Resistance/aerobic exercise or therapy alone did not improve depressive symptoms. Mind-body approaches were more effective than aerobic/resistance exercise or therapy alone for reducing pain and depression in people with osteoarthritis.Systematic review registration: PROSPERO CRD42022338051.

Protocol for a Parallel Group Randomized Clinical Trial Comparing a Culturally Adapted Cognitive Behavioral Telerehabilitation Intervention to Usual Physical Therapy for Latino Patients With Chronic Spine Pain

OBJECTIVE

Disparities exist in health care access, diagnosis, and treatment of chronic pain in Latino populations and other minority populations. Cognitive behavioral-based physical therapy (CBPT) interventions have been shown to be effective in predominantly non-Hispanic white populations with chronic spine pain. However, there is a need for culturally adapted CBPT interventions that focus on the conservative management of chronic spine pain. The primary purpose of the study described in this protocol is to test the efficacy of an adapted cognitive behavioral-based hybrid telerehabilitation intervention for Latino patients with chronic spine pain.

METHODS

A single-blind, 2-arm parallel group, superiority randomized clinical trial is planned to compare an adapted CBPT intervention to Usual Care physical therapy. Goal Oriented Activity for Latinos with chronic Spine pain (GOALS/Metas) is an 8-week hybrid telerehabilitation intervention that integrates guideline-based physical therapy and pain management interventions using cognitive behavioral approaches and has been adapted for Latino patients with chronic spine pain. Usual Care physical therapy will be administered based on institutional standards at the referring health center. Outcome measures will be evaluated preintervention and at 1-week, 3-months, and 6-months postintervention. The primary outcome is pain-related disability 1-week postintervention using the Brief Pain Inventory Pain Interference subscale. Secondary outcome measures include behavioral measures of functional activity, social participation, physical activity, and sleep. Determinants of treatment effect, including pain-related psychological measures, posture and movement, self-efficacy, treatment expectancy, and therapeutic alliance, will be included in the secondary moderation and mediation analyses.

IMPACT

This clinical trial will provide information on the extent to which an adapted CBPT hybrid telerehabilitation intervention is effective in reducing pain-related disability for Latino patients with chronic spine pain. This information will be useful for clinicians to integrate in their practice, given the growing population of Latino patients who experience disparities in health care management of chronic pain.

Persistent pain management in an oncology population through pain neuroscience education, a multimodal program: PaiNEd randomized clinical trial protocol

INTRODUCTION

Pain is one of the most persistent symptoms after cancer treatment. The central nervous system can erroneously stay in its alarm phase, altering the pain experience of patients who have cancer. Pain neuroscience education (PNE) with multimodal approaches may benefit these patients.

OBJECTIVE

This protocol aims to determine the effectiveness of a PNE tool on pain, physical function and quality of life, as a supplement to a multimodal rehabilitation (MR) program in patients who had breast cancer (BC).

METHODS

An 8-week double-blinded randomized controlled trial will be conducted, including 72 participants who had BC and who have persistent pain, randomized into three groups: PNE program + MR program, traditional biomedical information + MR program and control group. The PNE program will include educational content that participants will learn through a mobile app and the MR program will include a concurrent exercise program and manual therapy. The primary outcome will be the perceived pain assessed using the Visual Analogue Scale and secondary outcomes are others related to pain, physical function and quality of life. All outcomes will be evaluated at baseline, at the end of the intervention and 6 months after the end of intervention.

DISCUSSION

The proposed study may help BC patients with persistent pain improve their pain experience, quality of life and provide for more adaptive pain-coping strategies. This protocol could propose an action guide to implement different integral approaches for the treatment of sequelae. This treatment option could be offered to this patient profile and it could be easily implemented in the healthcare systems due to its low costs.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04877860. (February18, 2022).

Central Sensitization in Cancer Survivors and Its Clinical Implications: State of the Art

Although the prevalence of cancer pain is 47% after treatment, cancer pain is often underestimated, and many patients are undertreated. The complexity of cancer pain contributes to the lack of its management. Recently, as the mechanism of cancer pain, it has become clear that central sensitization (CS) influences chronic pain conditions and the transition from acute to chronic pain. In this state-of-the-art review, we summarized the association of CS or central sensitivity syndrome with pain and the treatment for pain targeting CS in cancer survivors. The management of patients with CS should not only focus on tissue damage in either the affected body regions or within the central nervous system; rather, it should aim to target the underlying factors that sustain the CS process. Pain neuroscience education (PNE) is gaining popularity for managing chronic musculoskeletal pain and could be effective for pain and CS in breast cancer survivors. However, there is a study that did not demonstrate significant improvements after PNE, so further research is needed. Precision medicine involves the classification of patients into subgroups based on a multifaceted evaluation of disease and the implementation of treatment tailored to the characteristics of each patient, which may play a central role in the treatment of CS.

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.

Conservative treatment for iliotibial band syndrome: Are we facing a research gap? A scoping review of 98 studies with clinical perspectives

OBJECTIVES

To identify which treatment modalities are described in the literature for the conservative management of ITBS (1) and to identify research gap (2).

DATABASES

The following electronic databases were searched: MEDLINE/Pubmed, Embase, Scopus and Cochrane Library.

ELIGIBILITY CRITERIA

The included studies had to report at least one conservative treatment on a human population suffering from ITBS.

RESULTS

98 studies reached the included criteria and seven categories of treatment were identified, i.e., stretching, adjuvants, physical modalities, injections, strengthening, manual techniques and education. Only 32 studies were designed as original clinical studies within which only 7 were randomized controlled trials, while 66 were review studies. Education, injections and medications as well as stretching were the most cited therapies. However, there was a clear discrepancy design. For example, stretching modalities were reported in 31% and 78% for clinical and review studies, respectively.

CONCLUSIONS

There is an objective research gap in the literature concerning conservative ITBS management. The recommendations are mostly based on expert opinions and review article. More high-quality research studies should be performed for enhancing the ITBS conservative management understanding.

Pain neuroscience education, blended exercises and booster sessions as an effective therapy for pain, functional and psychological factors in patients with knee osteoarthritis: a study protocol for a single-blind randomised controlled trial with 22 factorial design during 6-month follow-up

INTRODUCTION

This study aims to investigate whether a pain neuroscience education (PNE) combined with a blended exercises programme including aerobic, resistance, neuromuscular, breathing, stretching and balance exercises and diet education provides greater pain relief and improvement in functional and psychological factors than PNE and blended exercises alone and whether 'exercise booster sessions (EBS)' approach may improve outcomes and increase adherence in patients with knee osteoarthritis (KOA) (by telerehabilitation (TR)).

METHODS AND ANALYSIS

In this single-blind randomised controlled trial, 129 patients (both genders; age >40) diagnosed with KOA will be randomly assigned to one of the 22 treatment combinations as: (1) blended exercises alone (36 sessions over 12 weeks), (2) PNE alone (three sessions over 2 weeks), (3) combination of PNE with blended exercises (exercise three times a week for 12 weeks combined with three sessions of PNE) and (4) a control group. Outcome assessors will be blinded towards group allocation. The primary outcome variables are the visual analogue scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis index in knee osteoarthritis (WOMAC) score. Secondary outcomes include Pain Self-Efficacy Questionnaire (PSEQ), Depression, Anxiety and Stress Scale (DASS), Tampa Scale for Kinesiophobia (TSK), Short Falls Efficacy Scale International (FES-I), Pain Catastrophising Scale (PCS), Short Form Health Survey (SF-12) and Exercise Adherence Rating Scale (EARS), 30 s sit-to-stand test (30CST), Timed Up and Go (TUG), lower limbs' muscle strength and lower limb joints' active range of motion (AROM) will be performed at baseline, 3 and 6 months' postinterventions. The primary and secondary outcomes will assess at baseline, 3 months and 6 months postinterventions.The findings will be useful in establishing an effective treatment strategy covering multiple aspects behind KOA. The study protocol is conducted in clinical settings, thereby enhancing the possibility of future implementation of the treatments in the healthcare systems and self-care management. Results in comparison between groups will help to clarify the most effective of mixed-method TR (blended exercise, PNE, EBS with diet education) on more improvement in pain, functional and psychological factors in patients with KOA. This study will combine some of the most critical interventions, to be able to introduce a 'gold standard therapy' in the treatment of KOA.

ETHICS AND DISSEMINATION

The trial has been approved by the ethics committee for research involving human subjects of the Sport Sciences Research Institute of Iran (IR.SSRC.REC.1401.021). The study findings will be published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

IRCTID: IRCT20220510054814N1.

Implementation of an online pain science education for chronic musculoskeletal pain in Brazilian public health system: protocol for a hybrid type III randomised controlled trial with economic evaluation

BACKGROUND

Although clinical practice guidelines recommend pain education as the first-line option for the management of chronic musculoskeletal pain, there is a lack of pain education programmes in healthcare. Thus, digital health programmes can be an effective tool for implementing pain education strategies for public health. This trial will aim to analyse the implementation and effectiveness outcomes of three online pain science education strategies in the Brazilian public health system (SUS) for individuals with chronic musculoskeletal pain.

METHODS

We will conduct a hybrid type III effectiveness-implementation randomised controlled trial with economic evaluation. We will include adult individuals with chronic musculoskeletal pain, recruited from primary healthcare in the city of Guarapuava, Brazil. Individuals will be randomised to three implementation groups receiving a pain science education intervention (EducaDor) but delivered in different modalities: group 1) synchronous online; group 2) asynchronous videos; and group 3) interactive e-book only. Implementation outcomes will include acceptability, appropriateness, feasibility, adoption, fidelity, penetration, sustainability, and costs. We will also assess effectiveness outcomes, such as pain, function, quality of life, sleep, self-efficacy, and adverse effects. Cost-effectiveness and cost-utility analyses will be conducted from the SUS and societal perspectives. The evaluations will be done at baseline, post-intervention (10 weeks), and 6 months.

DISCUSSION

This study will develop and implement a collaborative intervention model involving primary healthcare professionals, secondary-level healthcare providers, and patients to enhance self-management of chronic pain. In addition to promoting better pain management, this study will also contribute to the field of implementation science in public health by generating important insights and recommendations for future interventions.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05302180; 03/29/2022).

Reductions in movement-associated fear are dependent upon graded exposure in chronic low back pain: An exploratory analysis of a modified 3-item fear hierarchy

OBJECTIVE

To explore the effectiveness of a modified fear hierarchy on measuring improvements in movement-associated fear in chronic low back pain.

METHODS

A modified 3-item fear hierarchy was created and implemented based on principles of graded exposure. This study was an exploratory analysis of the modified 3-item fear hierarchy from a larger clinical trial data set. Both groups received pain education and exercise, either bodyweight or strength training. Both groups performed item one on the hierarchy, the squat. Only the strength training group performed item 2, the deadlift. Neither group performed item 3, the overhead press. Analysis of Covariance and stepwise linear regression were used to explore results.

RESULTS

Improvement in movement-associated fear was conditional upon graded exposure. Both groups improved in the squat movement (p ≤ 0.05), which both performed. Only the strength training group improved in the deadlift (p ≤ 0.01), and neither improved in the overhead press (p ≥ 0.05).

CONCLUSION

Reductions in movement-associated fear are conditional upon graded exposure, based on the use of a novel modified 3-item fear hierarchy. Further research is needed to understand the utility of this tool in a patient-led approach to co-designing a graded exposure-based intervention.

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.

Comprehensive assessment and classification of upper and lower limb pain in athletes: a scoping review

BACKGROUND

Upper and lower limb (peripheral) pain is prevalent in athletes. Contemporary research prioritises multidimensional pain assessment and classification. This study aims to review comprehensive athlete pain assessment practices against the reference standard (International Olympic Committee, IOC Athlete Pain framework), identifying trends and highlighting gaps.

METHODS AND ANALYSIS

Six databases were searched using a comprehensive search strategy. This review followed the Joanna Briggs Institute standardised methodology for scoping reviews and is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Title and abstract, full-text screening and data charting were completed by two independent reviewers.

INCLUSION CRITERIA

Original research, systematic reviews and clinical practice guidelines reporting assessment or classification of pain in athletes of any age with chronic or acute peripheral pain in English on human participants from database inception.

RESULTS

470 studies with 175 different pain assessment tools were mapped against the IOC Athlete Pain Framework. Papers included tools from neurophysiological (470/100%), biomechanical (425/90%), affective (103/22%), cognitive (59/13%) and socioenvironmental (182/39%) domains. Pain classification was included in 108 studies (23%). 4 studies (0.85%) defined pain. Athletes with physical disability were included in 13 (3%) studies and no studies included athletes with intellectual disabilities. Socioeconomic factors were addressed in 29 (6%) studies.

DISCUSSION

Neurophysiological and biomechanical domains are frequently addressed. Affective, socioenvironmental and cognitive tools are under-represented. Potential tools for use by researchers and clinicians are highlighted. Defining and classifying pain and determining predominant pain mechanisms is needed in both research and clinical practice. More work on underrepresented populations is needed.

CONCLUSION

This review informs researchers and clinicians working with athletes in pain how pain assessment and classification is currently conducted and highlights future priorities.

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.

Implementation of a novel emergency department pain coach educator program: First year experience and evaluation

Background

The ongoing opioid epidemic and rising number of patients with chronic pain have highlighted the need for alternative and integrative pain management approaches. A number of evidence-based nonpharmacologic pain management strategies are available; however, these approaches remain underutilized due to barriers such as time limitations, cost, and lack of clinician training. The aim of this work was to implement a nonpharmacologic pain coach educator program that addresses these barriers. We report an evaluation of the first year of program implementation in the emergency department of a large safety-net hospital.

Methods

We implemented a multimodal pain coach educator program that included education on pain neuroscience and over-the-counter analgesic options, demonstration of integrative techniques, and nonpharmacologic toolkits for home use. Implementation strategies included electronic health record tools, training and promotion, clinical champions, and clinician recognition. We used the RE-AIM framework to guide evaluation of the first year of program implementation using data from the electronic health record, quantitative and qualitative program records, and patient-reported outcomes.

Results

In the first year of program implementation 550 pain coach educator sessions were conducted. Upon immediate session completion, 61% of patients felt the program was helpful, 39% were unsure at the time, and none reported session was not helpful. Clinician feedback was overwhelmingly positive. Program cost per patient was $344.35. Adaptations to first year intervention and implementation strategies included modifications of session delivery timing for accommodation of clinical workflows, additions to program content to align with patient characteristics, and changes to patient identification strategies in response to the coronavirus 19 pandemic.

Conclusions

The PAMI pain coach educator program provides a model for nonpharmacologic pain management programs which can be scaled up and adapted for other settings. This work demonstrates the importance of intervention and implementation strategy adaptations to enhance program reach and effectiveness.

Multidimensional evaluation of the pain profile as prognostic factor in individuals with hip or knee osteoarthritis receiving total joint replacement: protocol of a 2-year longitudinal prognostic cohort study

INTRODUCTION

Knee and hip osteoarthritis are two highly prevalent musculoskeletal pain conditions. Unsuccessful rates after hip/knee replacement range from 10% to 20%. Subjects with sensitisation manifestations are vulnerable to worse clinical outcomes. Most studies have analysed outcomes up to 1 year after surgery. The aim of this 2-year longitudinal study will be to evaluate sensory-related, psychological and psychophysical pain sensitisation manifestations and a potential epigenetic biomarker as prognostic clinical outcomes for the development of chronic postoperative pain after knee or hip replacement.

METHODS AND ANALYSIS

A prospective longitudinal study with a 2-year follow-up period will be conducted. The prognostic variables will include pain, function, related-disability, anxiety, depression, quality of life, sensitisation-associated symptoms, kinesiophobia, neuropathic pain and catastrophising, and expectative of the intervention will be assessed before surgery. We will also evaluate the presence of the Val158Met polymorphism as a possible epigenetic marker. Clinical outcomes including pain, related-disability and self-perceived satisfaction, sensitisation-associated symptoms and neuropathic pain will be assessed 3, 6, 12, 18 and 24 months after surgery. These variables will be used to construct three prediction models: (1) pain and function, (2) sensitisation-associated symptomatology and (3) neuropathic pain features classifying those patients in responders and non-responders. Data from knee or hip osteoarthritis will be analysed separately. Statistical analyses will be conducted with logistic regressions.

ETHICS AND DISSEMINATION

The study has been approved by the Ethics Committee of both institutions involved (Hospital Universitario Fundación Alcorcón (HUFA) 19-141 and Universidad Rey Juan Carlos (URJC) 0312201917319). Participants will sign the written informed consent before their inclusion. Study results will be disseminated through peer-reviewed publications and presentations at scientific meetings.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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

Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application

Chronic pain (CP) affects over 50 million Americans daily and represents a unique challenge for healthcare professionals due to its complexity. Across all health professions, only a small percentage of the curriculum is devoted to treating patients with CP. Unfortunately, much of the content is delivered passively via lecture without giving students an opportunity to practice the communication skills to effectively treat patients in the clinic. An interprofessional team of health educators identified 5 essential messages that students frequently struggle to convey to patients with CP. Those messages were based on interprofessional and profession-specific competencies to treat patients with CP from the International Association for the Study of Pain. The 5 messages highlighted the importance of (1) therapeutic alliance, (2) consistent interdisciplinary language, (3) patient prognosis, (4) evidence for pain medicine, surgery, and imaging, and (5) early referral to the interprofessional team. For each message, the team summarized relevant research supporting the importance of each individual message that could serve as a foundation for didactic content. The team then developed active learning educational activities that educators could use to have students practice the skills tied to each message. Each learning activity was designed to be delivered in an interprofessional manner.

Remotely Delivered Psychologically Informed Mindful Movement Physical Therapy for Pain Care: A Framework for Operationalization

Background

While there is recognition by the greater medical community and physical therapists to address the biopsychosocial needs of people with chronic, persistent pain, there are challenges in implementation and delivery including wide variability in interventions, lack of clear rationale, and absence of clinical models that are feasible and acceptable on a large scale. Important components for psychologically informed physical therapy (PiPT) for pain care include behavioral approaches (e.g., Acceptance and Commitment Therapy), mindfulness, pain neuroscience education, motivational interviewing (MI), and interoceptive skills-building. The Empower Veterans Program (EVP) Mindful Movement framework blends these components and emphasizes a mindfulness and self-compassion approach with MI and body-based experiential learning. This program was offered in-person at the Atlanta and Maryland VA Health Care Centers with published positive Patient Reported Outcomes (PRO) pre-COVID 19 crisis and shifted to entirely remote delivery in March 2020.

Objective

This paper offers an evidence-based and theory driven framework to operationalize a remotely delivered group-based psychologically informed mindful movement physical therapy intervention as part of an interdisciplinary pain care program.

Methods

Since 2021 PRO and demographics are collected using a survey administered through Qualtrics over a 12-month period at baseline, immediately post TelePain EVP, at 6 months, and at 12 months, with findings forthcoming.

Discussion/Results

Tele-pain EVP offers 6-9 groups a week with 7-9 veterans from Atlanta based team and 3-4 groups a week with 5-9 veterans from Maryland based team. Adaptations for remote delivery optimized mindfulness and active learning strategies including interoceptive skills-building and use of MI to support self-efficacy to trust, restore a sense of safety in the body, and explore adaptations for safe movement.

Conclusion

TelePain-EVP Mindful Movement provides a framework for other programs to translate for their populations and systems to further develop best practices in PiPT for pain care and integration into interdisciplinary care.

The effects of pain science education plus exercise on pain and function in chronic Achilles tendinopathy: a blinded, placebo-controlled, explanatory, randomized trial

ABSTRACT

Exercise is the standard of care for Achilles tendinopathy (AT), but 20% to 50% of patients continue to have pain following rehabilitation. The addition of pain science education (PSE) to an exercise program may enhance clinical outcomes, yet this has not been examined in patients with AT. Furthermore, little is known about how rehabilitation for AT alters the fear of movement and central nervous system nociceptive processing. Participants with chronic AT (N = 66) were randomized to receive education about AT either from a biopsychosocial (PSE) or from a biomedical (pathoanatomical education [PAE]) perspective. Simultaneously, all participants completed an exercise program over 8 weeks. Linear mixed models indicated that there were no differences between groups in (1) movement-evoked pain with both groups achieving a clinically meaningful reduction (mean change [95% CI], PSE: -3.0 [-3.8 to -2.2], PAE = -3.6 [-4.4 to -2.8]) and (2) self-reported function, with neither group achieving a clinically meaningful improvement (Patient-Reported Outcomes Measurement Information System Physical Function-PSE: 1.8 [0.3-3.4], PAE: 2.5 [0.8-4.2]). After rehabilitation, performance-based function improved (number of heel raises: 5.2 [1.6-8.8]), central nervous system nociceptive processing remained the same (conditioned pain modulation: -11.4% [0.2 to -17.3]), and fear of movement decreased (Tampa Scale of Kinesiophobia, TSK-17: -6.5 [-4.4 to -8.6]). Linear regression models indicated that baseline levels of pain and function along with improvements in self-efficacy and knowledge gain were associated with a greater improvement in pain and function, respectively. Thus, acquiring skills for symptom self-management and the process of learning may be more important than the specific educational approach for short-term clinical outcomes in patients with AT.