Enrique Lluch

• PT, MsC, PhD
• Professor at University of Valencia

Objective: To compare the effect of Neuromuscular Exercise (NME) plus Pain Science Education (PSE), Isolated NME, and usual care on brain function measured by electroencephalography (EEG), clinical, and psychosocial outcomes in patients with chronic pain due to knee osteoarthritis (KOA). Methods: A three-arm randomised controlled trial will be cond...

Background Dry needling (DN) has been demonstrated as an effective treatment for patients with fibromyalgia (FM). It is crucial to take into consideration catastrophizing, a psychological construct that could potentially undermine the short‐term efficacy of DN. Objective To analyze the effects of DN in the infraspinatus muscle on both local and re...

Author response to the JOSPT Letter to the Editor-in-Chief “Comment on “Which Portion of Physiotherapy Treatments’ Effect Is Not Attributable to the Specific Effects in People With Musculoskeletal Pain? A Meta-Analysis of Randomized Placebo-Controlled Trials” by Ezzatvar et al” J Orthop Sports Phys Ther 2024;54(12):784-785. doi:10.2519/jospt.2024.0...

Objective There is no established consensus for screening the spine in patients with shoulder pain. The aim of this study was to explore the role of the spine in shoulder pain and generate a set of recommendations for assessing the potential involvement of the spine in patients with shoulder pain. Methods A modified Delphi study was conducted thro...

BACKGROUND AND PURPOSE: Rotator cuff tears are commonly addressed through arthroscopic surgical intervention and postoperative rehabilitation exercises. The addition of postoperative Blood Flow Restriction Therapy (BFRT) in patients with arthroscopic rotator cuff repair has not been described in the literature. The purpose of this case report was t...

Introduction: The relationship between psychosocial factors and bodily pain in people with knee osteoarthritis (KOA) is unclear. Purpose: To examine whether widespread pain was associated with poorer self-efficacy, more anxiety, depression, and kinesiophobia in people with KOA. Methods: This was a cross-sectional study based on data from Good Life...

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, Em...

Background: Natural history of disease refers to the progression of a disease process in an individual over time, in the absence of treatment. Understanding natural history of tendinopathies is key for clinicians to make accurate prognostic predictions and design effective intervention studies. Objective: To quantify the natural history of the main...

BACKGROUND: the pathogenesis of frozen shoulder (FS) is thought to be one of inflammation and fibrosis possibly influenced by hyperglycemia. Biomechanical changes of the shoulder joint in terms of muscle strength, scapular kinematics and proprioception might occur in FS. OBJECTIVES: to compare muscle strength, scapular kinematics, proprioception, a...

Abstract OBJECTIVE: To quantify the proportion attributable to contextual effects of physical therapy interventions for musculoskeletal pain. DESIGN: Intervention systematic review with meta-analysis. LITERATURE SEARCH: We searched Ovid, MEDLINE, EMBASE, CINAHL, Scopus, PEDro, Cochrane Controlled Trials Registry, and SPORTDiscus databases from inc...

Introduction: Widespread pain may be related to psychosocial aspects in several musculoskeletal conditions, but the literature on carpal tunnel syndrome (CTS) is scarce. Objective: To determine the relationship between pain extent and psychological factors (catastrophizing, kinesiophobia, anxiety symptoms, and depression) in people with CTS. Method...

Objective The aim of this study is to review the implementation of the Frequency, Etiology, Direction, and Severity (FEDS) classification for shoulder instability by the physical therapy scientific community since its publication in 2011. Methods A systematic search was conducted on January 10, 2024 in the MEDLINE, EMBASE, SPORTDiscus, Scopus, Web...

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...

Introduction Rotator cuff calcific tendinopathy (RCCT) involves calcific deposits in the rotator cuff. Non-surgical interventions such as extracorporeal shockwave therapy (ESWT) and ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT) are recommended for its early management. Exercise therapy (ET) has shown to be an effectiv...

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 exer...

Objective To identify tendon transfer surgeries and post‐surgical physical therapy interventions in people with massive rotator cuff (RC) tears. Methods The literature search was conducted in the MEDLINE, Science Direct, Scopus, Web of Science, and PEDro databases from inception to September 2022. Studies with patients diagnosed with massive RC te...

Background Altered central pain processing (CPP) and dysautonomia might play a role in the clinical course of frozen shoulder and psychological factors, like pain catastrophizing and hypervigilance, might influence clinical variables in frozen shoulder. Objectives To explore the clinical course of frozen shoulder regarding CPP, dysautonomia, pain c...

Background Knee osteoarthritis is a highly prevalent disease worldwide that leads to functional disability and chronic pain. It has been shown that not only changes are generated at the joint level in these individuals, but also neuroplastic changes are produced in different brain areas, especially in those areas related to pain perception, therefo...

Background: Contradictory evidence exists regarding the clinical course of frozen shoulder (FS). Objectives: To explore the clinical course of FS regarding disabilities, pain, range of motion (ROM), muscle strength, scapular upward rotation, and proprioception and to establish longitudinal correlations between these variables. Methods: Patient...

Whiplash-Associated Disorders (WAD) represent a multifactorial condition often accompanied by altered nociceptive processing and psychological factors. This systematic review on acute and chronic WAD aimed to investigate the relationship between Quantitative Sensory Testing (QST) and psychological factors and quantify whether their trajectories ove...

OBJECTIVE: To create a consensus-based framework of manual therapy treatment approaches for the major mechanisms-based pain classifications established by the International Association for the Study of Pain (IASP) nociceptive, nociplastic, and neuropathic pain. DESIGN: The hybridized consensus survey included experts who participated in working gro...

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 tr...

Background: Among the most effective therapeutic interventions in non-specific chronic low back pain (NSCLBP), clinical practice guidelines highlight exercise therapy and patient education; However, regarding the combined intervention of exercise and Pain Neuroscience Education (PNE), there is no consensus on the most effective form of exercise....

Background: Frozen shoulder (FS) is a highly disabling pathology of poorly understood etiology, which is characterized by the presence of intense pain and progressive loss of range of motion (ROM). The aim of this study was to evaluate the effect of adding a central nervous system-focused (CNS) approach to a manual therapy and a home stretching pr...

Objectives: To determine the most appropriate terminology and issues related to clinical reasoning, examination and treatment of the kinetic chain (KC) in people with shoulder pain by an international experts panel. Design: Delphi study METHODS: A three-round Delphi study that involved an international panel of experts with extensive clinical, t...

Introduction There is a large diversity in the clinical presentation of frozen shoulder (FS) and the clinical outcome is not always satisfactory. The aim of the current study was to examine to what extent range of motion (ROM) limitation, metabolic factors (diabetes mellitus and thyroid disorders), autonomic symptoms and pain sensitivity may contri...

Introduction: The On&Out study is aimed at assessing the effectiveness, cost-utility and physiological underpinnings of the FIBROWALK multicomponent intervention conducted in two different settings: online (FIBRO-On) or outdoors (FIBRO-Out). Both interventions have proved to be efficacious in the short-term but there is no study assessing their com...

En sujetos con dolor de hombro relacionado con el manguito rotador (DHRMR) el ejercicio de baja carga es el tratamiento recomendado. El entrenamiento con restricción de flujo (BFR) puede aportar beneficios añadidos al ejercicio.

Objectives: The pathophysiology of frozen shoulder (FS) is thought to be related to chronic inflammation. Chronic inflammation may disturb the immune system and consequently the nervous system as part of an overarching system. The aim of this study was to determine the presence of disturbed autonomic nervous system function and altered central pai...

Nowadays, there is evidence that relates the amount of physical activity, as well as the impact of psychological factors, to the intensity of symptoms present in patients with fibromyalgia (FM). However, there are no studies which correlate the level of association of physical activity, psychological factors and vegetative symptoms in the FM popula...

Background/Objectives The aim of this study was to examine the effectiveness of two video-based multicomponent programs (FIBROWALK) and the Multicomponent Physiotherapy Program (MPP) for patients with fibromyalgia (FM) compared to treatment-as-usual (TAU) only. We posit that FIBROWALK, due to inclusion of specific psychological ingredients (cogniti...

Background Structural and functional impairments of the cervical extensor muscles have been demonstrated in people with neck pain. A global exercise approach targeting all neck extensor muscles has shown positive effects in this population. However, to date, the efficacy of exercises specifically targeting the deep neck extensors has neither been t...

This study aimed to investigate changes in the pain sensory profile of women with breast cancer. Five women with unilateral breast cancer were enrolled. Participants were assessed with direct (quantitative sensory testing, QST) and indirect measures of pain sensitization (self-reported central sensitization inventory, CSI) at baseline (before surge...

Objectives: To longitudinally investigate the relationships between neck/arm disability and pain profile measures in individuals with chronic nonspecific neck pain (NSNP) at baseline, one month, and six months after a standardized physiotherapy intervention. A secondary aim was to compare pain sensitivity of individuals with chronic NSNP at baseli...

Background: Frozen shoulder (FS) is a highly disabling pathology of poorly understood etiology, which is characterized by the presence of intense pain and progressive loss of range of motion (ROM). The aim of this study is to evaluate the feasibility and clinical impact of a CNS-focused treatment program for people with FS. Methods: 10 subjects...

Background There is a lack of standardized criteria for diagnosing Rotator Cuff Related Shoulder Pain (RCRSP). Objective To identify the most relevant clinical descriptors for diagnosing RCRSP. Methods A Delphi study was conducted through use of an international physical therapists expert panel. A 3-round Delphi survey involving an international...

The aim of this cross-sectional study was to explore the spatial extent of pain and its association with clinical symptoms, psychological features, and pain sensitization in people with frozen shoulder (FS). Forty-eight individuals with FS completed pain drawings (PDs) and reported their clinical symptoms including pain intensity (Visual Analogue S...

The current systematic review aimed to compare the effect of injury-focused (specific) exercises versus more general (non-specific) exercises on pain in patients with chronic neck or shoulder pain. We searched PubMed, EMBASE, and Web of Science. Two reviewers screened and selected studies, extracted outcomes, assessed risk of bias, and rated the qu...

Frozen shoulder (FS) is a poorly understood condition resulting in substantial shoulder pain and mobility deficits. The mechanisms behind FS are not yet fully understood, but, similar to other persistent pain states, central pain mechanisms may contribute to ongoing symptoms in this population. The objective of this research was to investigate cond...

Background Impairments of sensorimotor control relating to head and eye movement control and postural stability are often present in people with neck pain. The upper cervical spine and particularly the obliquus capitis inferior (OCI) plays an important proprioceptive role; and its impairment may alter cervical sensorimotor control. Dry needling (DN...

Objective: This explorative study investigates the moderating effect of sex and baseline pain characteristics on the effectiveness of preoperative pain neuroscience education (PNE) plus knee joint mobilization versus biomedical education plus knee joint mobilization in patients who have knee osteoarthritis and are scheduled to undergo total knee a...

Exercise can reduce pain, however the effect of painful versus non-painful exercises is uncertain. The primary aim of this randomized cross-over study was to compare the effect of painful versus non-painful isometric shoulder exercises on pain intensity after exercise in individuals with rotator cuff-related shoulder pain (RCRSP). Secondary explora...

Background Nonspecific chronic low back pain (NSCLBP) is one of the most common and frequent health problems. Objetive to compare postural control (i.e. centre of pressure (CoP) displacement and energy spectral density (ESD)) using technological devices (accelerometers and pressure platform) between subjects with NSCLBP and healthy subjects. Meth...

There is an increasing incidence, prevalence, and burden of knee osteoarthritis due to a global increase in obesity and an aging population. The aim of the present study was to compare the effectiveness of the addition of aerobic exercises performed in an unloaded or loaded position to a conventional exercise program in overweight subjects with kne...

Female family caregivers (FFCs) constitute one of the basic supports of socio-health care for dependence in developed countries. The care provided by FFCs may impact their physical and mental health, negatively affecting their quality of life. In order to alleviate the consequences of providing care on FFCs, the Spanish Public Health System has dev...

Background: Frozen shoulder (FS) is a highly disabling pathology of poorly understood etiology, which is characterized by the presence of intense pain and progressive loss of range of motion (ROM). The aim of this study was to evaluate the feasibility and clinical impact of a CNS-focused treatment program for people with frozen shoulder (FS). Metho...

Objective To determine the effectiveness of mechanical diagnosis and therapy (MDT) in patients with chronic low back pain (CLBP) compared to other traditional physical therapy interventions. Methods Randomized controlled trials investigating the effect of MDT compared to other traditional physical therapy interventions in individuals with CLBP wer...

Background The purpose of this study was to evaluate the effect of low-frequency self-administered vibration therapy into myofascial trigger points in the upper trapezius and levator scapulae on patients with chronic non-specific neck pain. Methods Twenty-eight patients with chronic non-specific neck pain were randomly assigned into a vibration gr...

Chronic musculoskeletal pain affects more than 20% of the population, leading to high health care overload and huge spending. The prevalence is increasing and negatively affects both physical and mental health, being one of the leading causes of disability. The most common location is the spine. Most treatments used in the Public Health Services ar...

Objective: To investigate the effects of the inclusion of motor imagery (MI) principles into early physical therapy on pain, disability, pressure pain thresholds (PPTs), and range of motion in the early postsurgical phase after total knee arthroplasty (TKA). Methods: A randomized clinical trial including patients with knee osteoarthritis who hav...

Background: Disrupted tactile acuity and poor laterality judgement have been shown in several chronic musculoskeletal pain conditions. Whether they are impaired in people with frozen shoulder (FS) remains unknown. Objectives: To determine whether there is impairment in tactile acuity and laterality judgement in subjects with FS. Methods: Thirt...

Background: Chronic musculoskeletal pain affects more than 20% of the population, and the prevalence is increasing, causing suffering, loss of quality of life, disability, and an enormous expenditure on healthcare resources. The most common location for chronic pain is the spine. Many of the treatments used are mainly passive (pharmacological and...

BACKGROUND: Frozen shoulder (FS) is a musculoskeletal condition of poorly understood etiology that results in shoulder pain and large mobility deficits. Despite some physical therapy interventions, such as joint mobilization and exercise, having shown therapeutic benefit, a definitive treatment does not currently exist. The aim of this study will b...

Objective: To assess the effect of different dosages of pain neuroscience education (PNE) programs on central nociceptive processing in patients with fibromyalgia. Second, to compare the effects of different dosages of PNE programs on numerical pain rating scale (NPRS), disability, and psychological variables. Design: Single-blind randomized con...

Background: Most of the research on the effects of spinal manipulation on endocrine function has been done on healthy subjects and has yielded contradictory results. The potential role of cervical manual therapy intervention in order to induce changes in the endocrine system has not yet been investigated. Aim: To compare the effects on salivary co...

Objectives: The “figure-of-four” position is a clinical test used to examine flexibility of the anterior hip joint structures. The objective of this study was to examine the intra- and inter-tester reliability, concurrent criterion-related validity and responsiveness to treatment of the “figure-of-four” position. Methods: A total of 52 asymptomatic...

Background The role of contextual factors like pre‐existing treatment expectations has been established. However, the effect of verbally‐delivered treatment expectations in patient‐therapist communication has not been considered, nor the role of cortisol changes within the placebo/nocebo response in people with chronic neck pain. Objective To exam...

Background Manual therapy has been demonstrated to reduce pain and improve function in patients with frozen shoulder contracture syndrome (FSCS), but no evidence exists to support one form of manual therapy over another. This case series describes both short- and long-term outcomes after a manual therapy program and home stretching exercises based...

Background: Passive oscillatory mobilizations are often employed by physiotherapists to reduce shoulder pain and increase function. However, there is little data about the neurophysiological effects of these mobilizations. Objectives: To investigate the initial effects of an anteroposterior (AP) shoulder joint mobilization on measures of pain an...

As a potential high-yield tool for disseminating information that can reach many people, social media is transforming how clinicians, the public, and policy makers are educated and find new knowledge associated with research-related information. Social media is available to all who access the internet, reducing selected barriers to acquiring origin...

Background: The therapeutic value of proprioceptive-based exercises in knee osteoarthritis (KOA) management warrants investigation of proprioceptive testing methods easily accessible in clinical practice. Objective: To estimate inter- and intrarater reliability of the knee joint position sense (KJPS) test and knee force sense (KFS) test in subje...

ABSTRACT Aim: To assess the effect of a pain neurophysiology education program plus therapeutic exercise for patients with chronic low back pain (CLBP). Design: Single-blind randomized controlled trial. Setting: Private clinic (Clínica Bonn) and Alcalá de Henares University, Madrid, Spain. Participants: 56 patients with CLBP for 6 months or more. I...

Background: Despite growing awareness of the contribution of central pain mechanisms to knee osteoarthritis pain in a subgroup of patients, routine evaluation of central sensitization is yet to be incorporated into clinical practice. The objective of this perspective is to design a set of clinical descriptors for the recognition of central sensitiz...

OBJECTIVES: This study aimed to first compare the effects of a preoperative treatment combining pain neuroscience education (PNE) with knee joint mobilization versus biomedical education with knee joint mobilization on central sensitization (CS) in patients with knee osteoarthritis, both before and after surgery. Second, we wanted to compare the ef...

Background: A depressed scapular alignment could lead to prolonged and repetitive stress or compression of the brachial plexus, resulting in sensitization of neural tissue. However, no study has investigated the influence of alignment of the scapulae on sensitization of upper limb neural tissue in otherwise asymptomatic people. In this case-contro...

Chronic neck pain attributed to a myofascial pain syndrome is characterized by the presence of muscle contractures referred to as myofascial trigger points (MTrPs). In this randomized, parallel-group, blinded, controlled clinical trial we examined the effectiveness of deep dry needling of myofascial trigger points in people suffering from chronic n...

Background: Expanded distribution of pain is considered a sign of central sensitization (CS). The relationship between recording of symptoms and CS in people with knee osteoarthritis (OA) has been poorly investigated. Objective: To examine whether the area of pain assessed using pain drawings (PDs) relates to CS and clinical symptoms in people with...

Objective: To compare the effects of cranio-cervical flexion vs cervical proprioception training on neuromuscular control, pressure pain sensitivity and perceived pain and disability in patients with chronic neck pain. Methods: Twenty-eight volunteers with chronic non-specific neck pain were randomly assigned to 1 of 2 interventions and undertoo...

Manual therapy (MT) is a passive, skilled movement applied by clinicians that directly or indirectly targets a variety of anatomical structures or systems, which is utilized with the intent to create beneficial changes in some aspect of the patient pain experience. Collectively, the process of MT is grounded on clinical reasoning to enhance patient...

OBJECTIVE: A systematic review was performed to evaluate the existing evidence related to the prevalence, incidence, localization, and pathophysiology of myofascial trigger points (MTrPs) in patients with spinal (back and neck) pain. METHODS: A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines...

OBJECTIVE: The aim of this study is to systematically review whether the presence of altered central pain modulation pre-surgical influences outcome after total knee replacement (TKR) in patients with knee osteoarthritis (OA), and if so which indices of central pain modulation predict poor outcome after TKR. METHODS: To identify relevant articles,...

It has been suggested that differential diagnosis of headaches should consist of a robust subjective examination and a detailed physical examination of the cervical spine. Cervicogenic headache (CGH) is a form of headache that involves referred pain from the neck. To our knowledge, no studies have summarized the reliability and diagnostic accuracy...

Low back pain (LBP) is a heterogeneous disorder including patients with dominant nociceptive (e.g., myofascial low back pain), neuropathic (e.g., lumbar radiculopathy), and central sensitization pain. In order to select an effective and preferably also efficient treatment in daily clinical practice, LBP patients should be classified clinically as e...

Background: Apart from the cranio-cervical flexion test and the deep neck flexor endurance test, evidence related to reliability of cervical movement control dysfunction tests is lacking. Objectives: This study investigated the inter- and intra-tester reliability of a battery of cervical movement control dysfunction tests and the effect of clini...

Shoulder pain is often a challenging clinical phenomenon because of the potential mismatch between pathology and the perception of pain. Current evidence clearly emphasizes an incomplete understanding of the nature of shoulder pain. Indeed, the effective diagnosis and treatment of shoulder pain should not only rely upon a detailed knowledge of the...

Hyperexcitability of the central nervous system (CNS) has been suggested to play an important role in the chronic pain experienced by osteoarthritis (OA) patients. A systematic review following PRISMA guidelines was performed to evaluate the existing evidence from the literature related to the presence of central sensitization (CS) in patients with...

We would like to thank Helena Hachul, Marcele Siegler, Cristina Frange, Monica L. Andersen and Sergio Tufik for their positive feedback on our recently published professional issue article on altering pain memories as part of exercise therapy for chronic musculoskeletal pain (Nijs et al., 2014). In addition, Hachul et al. highlighted some important...

OBJECTIVE: The purpose of this study was to investigate the effect of active vs passive scapular correction on pain and pressure pain threshold at the most symptomatic cervical segment in patients with chronic neck pain. METHODS: Twenty-three volunteers with chronic, idiopathic neck pain were recruited (age, 38.9 ± 14.4 years; sex [man/woman], 3/20...

The awareness is growing that central sensitization is of prime importance for the assessment and management of chronic pain, but its classification is challenging clinically since no gold standard method of assessment exists. Objectives: Designing the first set of classification criteria for the classification of central sensitization pain. Method...

Traditional understanding of osteoarthritis-related pain has recently been challenged in light of evidence supporting a key role of central sensitization in a subgroup of this population. This fact may erroneously lead musculoskeletal therapists to conclude that hands-on interventions have no place in OA management, and that hands-off interventions...

Even though nociceptive pathology has often long subsided, the brain of patients with chronic musculoskeletal pain has typically acquired a protective (movement-related) pain memory. Exercise therapy for patients with chronic musculoskeletal pain is often hampered by such pain memories. Here the authors explain how musculoskeletal therapists can al...

Results on the effects of lateral wedge insoles (LWIs) in patients with medial knee osteoarthritis (OA) are ambiguous and not fully understood. Because of the low cost of this intervention and its clinical utility, attention to LWIs is worth considering. Current insights on the efficacy of LWIs are mainly focused on changing biomechanical aspects,...