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Objective: Systematic review of randomized control trials (RCTs) for the effectiveness of pain neuroscience education (PNE) on pain, function, disability, psychosocial factors, movement, and healthcare utilization in individuals with chronic musculoskeletal (MSK) pain. Data sources: Systematic searches were conducted on 11 databases. Secondary searching (PEARLing) was undertaken, whereby reference lists of the selected articles were reviewed for additional references not identified in the primary search. Study selection: All experimental RCTs evaluating the effect of PNE on chronic MSK pain were considered for inclusion. Additional Limitations: Studies published in English, published within the last 20 years, and patients older than 18 years. No limitations were set on specific outcome measures. Data extraction: Data were extracted using the participants, interventions, comparison, and outcomes (PICO) approach. Data synthesis: Study quality of the 13 RCTs used in this review was assessed by 2 reviewers using the PEDro scale. Narrative summary of results is provided for each study in relation to outcomes measurements and effectiveness. Conclusions: Current evidence supports the use of PNE for chronic MSK disorders in reducing pain and improving patient knowledge of pain, improving function and lowering disability, reducing psychosocial factors, enhancing movement, and minimizing healthcare utilization.
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REVIEW
The efficacy of pain neuroscience education on musculoskeletal pain:
A systematic review of the literature
Adriaan Louw, PT, PhD
a
, Kory Zimney, PT, DPT
b
, Emilio J. Puentedura, PT, DPT, PhD
c
, and Ina Diener, PT, PhD
d
a
International Spine and Pain Institute, Story City, IA, USA;
b
Department of Physical Therapy, School of Health Sciences, University of South
Dakota, Vermillion, SD, USA;
c
Department of Physical Therapy, School of Allied Health Sciences, University of Nevada, Las Vegas, Las Vegas,
NV, USA;
d
Department of Physiotherapy, Stellenbosch University, Stellenbosch, South Africa
ABSTRACT
Objective: Systematic review of randomized control trials (RCTs) for the effectiveness of pain
neuroscience education (PNE) on pain, function, disability, psychosocial factors, movement, and health-
care utilization in individuals with chronic musculoskeletal (MSK) pain. Data Sources: Systematic
searches were conducted on 11 databases. Secondary searching (PEARLing) was undertaken, whereby
reference lists of the selected articles were reviewed for additional references not identified in the
primary search. Study Selection: All experimental RCTs evaluating the effect of PNE on chronic MSK pain
were considered for inclusion. Additional Limitations: Studies published in English, published within
the last 20 years, and patients older than 18 years. No limitations were set on specific outcome measures.
Data Extraction: Data were extracted using the participants, interventions, comparison, and outcomes
(PICO) approach. Data Synthesis: Study quality of the 13 RCTs used in this review was assessed by
2 reviewers using the PEDro scale. Narrative summary of results is provided for each study in relation to
outcomes measurements and effectiveness. Conclusions: Current evidence supports the use of PNE
for chronic MSK disorders in reducing pain and improving patient knowledge of pain, improving
function and lowering disability, reducing psychosocial factors, enhancing movement, and minimizing
healthcare utilization.
ARTICLE HISTORY
Received 12 November 2015
Revised 19 December 2015
Accepted 26 January 2016
KEYWORDS
Chronic pain; explain pain;
pain neuroscience
education; therapeutic
neuroscience education
Introduction
Pain is a normal human experience and the inability to
experience pain provides a significant risk to survival
for any human being (Gifford, 2014; Moseley, 2003a;
Moseley, 2007). Living in pain though is not a normal
human experience and a powerful motivating force to
seek help (Bernard and Wright, 2004; Louw, Louw, and
Crous, 2009; Mortimer et al., 2003). One treatment
strategy aimed at helping ease pain and often the
associated suffering and disability is patient education
(Brox et al., 2008; Engers et al., 2008; Heymans et al.,
2005; Liddle, Gracey, and Baxter, 2007). Traditional
musculoskeletal (MSK) education models have focused
heavily on biomedical education focusing on anatomy,
biomechanics, and pathoanatomy (Brox et al., 2008;
Maier-Riehle and Härter, 2001; Moseley, 2003a,2004).
In these educational models clinicians aim to explain a
pain experience to patients from a tissue perspective, be
it contrasting healthy (anatomy) and injured tissues
(pathoanatomy) or highlighting a mechanical deviance
from normal expected patterns of movement (biome-
chanics) or a disease state such as degenerative changes
(pathoanatomy) (Haldeman, 1990; Louw and Butler,
2011). Although these models may have clinical value
in more acute phases of injury, surgical, or disease
states, they lack the ability to explain complex issues
associated with pain, including peripheral and central
sensitization, facilitation and inhibition, neuroplasticity,
immune and endocrine changes, and more, all of which
have been implicated in more complex and persistent
pain states (Gifford, 2014; Moseley, 2003a; Nijs et al.,
2013; Woolf, 2007). Furthermore, these biomedical
educational models have not only shown limited effi-
cacy in alleviating pain and disability (Brox et al., 2008;
Koes, van Tulder, van der Windt, and Bouter, 1994;
Maier-Riehle and Härter, 2001; Waddell, 2004) but may
even increase patient fears, anxiety, and stress, thus
negatively impacted their intended outcomes (Hirsch
and Liebert, 1998; Maier-Riehle and Härter, 2001;
Nachemson, 1992; Poiraudeau et al., 2006).
In lieu of the limited efficacy of traditional education to
alleviate pain and disability, especially in persistent pain, a
new model was needed and proposed (Butler and
Moseley, 2003; Gifford, 1998; Gifford, 2014;Giffordand
Butler, 1997; Gifford and Muncey, 1999;Moseleyand
Butler, 2015). People in pain are interested in learning
CONTACT Adriaan Louw, PT, PhD adriaan@ispinstitute.com International Spine and Pain Institute, P.O. Box 232, Story City, IA 50248, USA.
PHYSIOTHERAPY THEORY AND PRACTICE
http://dx.doi.org/10.1080/09593985.2016.1194646
© 2016 Taylor & Francis
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more about their pain (Louw, Louw, and Crous, 2009;
Louw, Diener, Butler, and Puentedura, 2013;Moseley,
2003b;Rönnbergetal.,2007). This educational model of
teaching people about pain biology and physiology is
called therapeutic neuroscience education (Louw,
Puentedura, Diener, and Peoples 2015; Zimney, Louw,
and Puentedura, 2014), explain pain (Butler and
Moseley, 2003; Moseley and Butler, 2015), and pain neu-
roscience education (PNE) (Nijs et al., 2011,2013). PNE
aims to explain to patients the biological and physiologi-
cal processes involved in a pain experience and, more
importantly, defocus the issues associated with the anato-
mical structures (Louw, Diener, Butler, and Puentedura,
2011;Moseley,2007; Moseley, Nicholas, and Hodges,
2004; Nijs et al., 2011,2013). Following early calls for
the further study and clinical application of PNE
(Gifford, 1998;GiffordandButler,1997)andthefirst
conference presentation of explaining pain to patients
(Gifford and Muncey, 1999), scientists used an evi-
dence-based platform to further investigate PNE.
Subsequently, various randomized controlled trials
(RCT) and two systematic reviews explored the efficacy
of PNE (Clarke, Ryan, and Martin, 2011; Louw, Diener,
Butler, and Puentedura, 2011;Meeusetal.,2010; Moseley,
2002; Moseley, Nicholas, and Hodges, 2004; Ryan, Gray,
Newton, and Granat, 2010). At the end of 2011, the
systematic review of Louw, Diener, Butler, and
Puentedura (2011) demonstrated for MSK pain, TNE
provides compelling evidence in reducing pain, disability,
pain catastrophization, and limited physical movement.
The review by Louw, Diener, Butler, and Puentedura
(2011) included eight studies (Meeus et al., 2010;
Moseley, 2002,2003b,2003c,2004; Moseley, Nicholas,
and Hodges, 2004; Ryan, Gray, Newton, and Granat,
2010; Van Oosterwijck et al., 2011), ranging in date
from 2002 (Moseley, 2002) to 2011 (Van Oosterwijck
et al., 2011). Since the publication of the last systematic
review, various studies utilizing PNE have been pub-
lished (Gallagher, McAuley, and Moseley, 2013;
Ittersum et al., 2014; Louw, Diener, Landers, and
Puentedura, 2014; Robinson and King, 2011; Van
Ittersum, van Wilgen, Groothoff, and Van der Schans,
2011). This growth of additional PNE studies, along
with the reflection by Moseley and Butler (2015)on
15 years of teaching people about pain begs the ques-
tion if the increased research activity in PNE has
resulted in any increased evidence for this educational
approach? The original review was also handicapped in
assessing efficacy by including lower level papers and
the inability to evaluate methodologically each study in
comparative fashion. The goal of this systematic review
is to update and explore the efficacy of PNE as a
treatment approach for people suffering MSK pain.
Methods
In line with the goal of the updated systematic review,
the authors used the same methodology reported by
Louw, Diener, Butler, and Puentedura (2011)asa
means to add to and thus combine the cumulative
evidence for PNE. The end result would be an expan-
sion of the research results ranging from 2002
(Moseley, 2002) to the present. Additionally, the new
review only included RCTs.
Search strategy
An electronic search was performed between June 2015
and August 2015, covering the last 14 years (20022015)
from the following databases: Biomed Central, BMJ.com,
CINAHL, the Cochrane Library, NLM Central Gateway,
OVID, ProQuest (Digital Dissertations), PsycInfo,
PubMed/Medline, ScienceDirect, and Web of Science.
Each database has its own indexing terms and functions,
and therefore different search strategies were developed
for each database by the authors. The main search
items were education, neuroscience, neurobiology, neu-
rophysiology, pain, pain education, pain science, and
therapeutic. In PubMed, medical subject headings
(MeSH) terms were used where possible, with Boolean
operators. The search strategies for remaining databases
included synonyms of the main search items. Secondary
searching (PEARLing) was undertaken, whereby refer-
ence lists of the selected articles were reviewed for
additional references not identified in the primary search.
The titles and abstracts of all the identified literature were
screened by one primary reviewer using the inclusion
criteria below. The full text of all potentially relevant
articles were retrieved and screened by two reviewers
using the same criteria, in order to determine the
eligibility of the paper for inclusion in the review.
Inclusion criteria
All titles and abstracts were read to identify relevant
papers. Papers were included in this systematic review
if they met the inclusion criteria listed in Table 1. Given
the heterogeneous nature of the original systematic
reviews outcome measures, no parameters were set
on the exact measurement tools used to assess the effect
of PNE on patients suffering from MSK pain. When
there was uncertainty regarding the eligibility of the
paper from the abstract, the full text version of the
paper was retrieved and evaluated against the inclusion
criteria. The full text version of all papers that met the
inclusion criteria were retrieved for quality assessment
and data extraction.
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Quality assessment
Critical appraisal of each included study was conducted
by determining the level of evidence on the Australian
National Health and Medical Research Council
(NHMRC) Hierarchy of Evidence (National Health
and Medical Research Council, 1999). This provides a
broad indication of bias based on study design. Studies
higher on the hierarchy potentially contain less bias
than those that are lower on the hierarchy. Given the
increased activity in the field of PNE, study designs
other than RCT were excluded in this review because
of the lower level of evidence they provide.
Methodological quality of the design and reporting of
each study was assessed against the PEDro scale (Elkins
et al., 2010). The PEDro scale has become widely used to
rate physical therapy interventions and has been shown
to have reliability and a valid measure of methodological
quality of clinical trials (de Morton, 2009; Maher et al.,
2003). A high-quality study was defined by the authors
as scoring positive on a minimum of 50% (5/10) of
the items. Each reviewer conducted an independent
evaluation and PEDro scoring of the studies in the
review. The Physiotherapy Evidence Database was
cross-referenced for any article already having a
confirmed review, and the confirm score was used if
present. If differences were found between reviewers,
a discussion was held to attempt consensus. Any differ-
ences that could not be agreed upon were to be evaluated
by a third reviewer (E. J. Puentedura) to come to a final
judgement among all reviewers. No disagreements in
PEDro scoring occurred during assessment of the
articles.
Outcome assessment
Due to the heterogeneous nature of the original systema-
tic reviews outcome measures and to determine the
possible influence of PNE for MSK pain, results were
posted in narrative form and outcomes were defined as
positive(experimental group obtained a significantly
greater improvement than the control group); neutral
(there were no statistically significant differences
between the groups); or negative(the control group
obtained a significant greater improvement than the
experimental group). An alpha of p<0.05wasusedto
define a significant outcome measure. This method, used
in previous systematic reviews, demonstrated four levels
of scientific evidence on the quality and the outcome of
the trials: (1) strong evidence: multiple, relevant, high-
quality RCTs with generally consistent outcomes;
(2) moderate evidence: one relevant, high-quality RCT
AND one or more relevant, low-quality RCTs with gen-
erally consistent outcomes; (3) limited evidence: one
relevant, high-quality RCT OR multiple relevant low-
quality RCTs with generally consistent outcomes; and
(4) inconclusive evidence: only one relevant, low-quality
RCT, no relevant RCTs or randomized trials with
inconsistent outcomes (Ezzo et al., 2000; Fernández-de-
las-Peñas et al., 2006).
A study was considered relevantwhen at least one
of the outcome measures concerned pain or disability.
For being generally consistent,at least 75% of the
trials that analyzed the same PNE had to have the
same result (positive, neutral, or negative).
Data extraction
Data were extracted by the authors using the PICO
approach: Participants: diagnosis treated, age, sex, dura-
tion of the symptoms, type of referral source,
and diagnostic criteria; Interventions: type, intensity,
duration, educational tools/props, in combination or
stand-alone physical therapy; Comparison: to another
treatment, no treatment, or usualtreatment; and
Outcomes: domains and tools used to measure the effects
of the intervention. Although outcomes were not speci-
fied or limited, primary outcomes in line with relevance
stated above included pain and/or function (Stone, 2002).
Data on the effectiveness of the PNE were also
extracted for each study. To determine the effect of
the PNE on each outcome measure, the mean and
95% confidence intervals (CI) for the between-group
differences were calculated for RCTs and comparative
studies, based on the results provided in each article
Table 1. Inclusion criteria used in the systematic review.
Criterion Justification
English language Search reviewersprimary language is English, and major journals in the subject area are published in
English.
19992015 First study found was published in 2002.
Humans older than 18 years Increase homogeneity of participants between studies as educational needs for infants, children, and
adolescents.
MSK pain Increase homogeneity of participants being treated with educational strategies incorporating PNE.
RCTs Utilization of Level 1 evidence according to Centre for Evidence-based Medicine.
PNE Increase homogeneity on type of educational intervention.
Outcomes: pain, function, psychosocial factors,
movement, healthcare utilization
These are primary outcome measurements performed in the literature regarding individuals with
MSK pain. No limitation was set on specific measurement tools utilized to examine effect on
outcomes in these areas.
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(Herbert, 2000). Moreover, the mean changes between
pre- and post-treatment (and 95% CI) were calculated
for the RCTs. Pain reduction of more than 20%, irre-
spective of the measurement tool used, was considered
clinically worthwhile (Farrar et al., 2001; Ferreira et al.,
2002). It was expected that there would be heterogene-
ity in participants, interventions, comparisons, and
outcomes. Therefore, the results of the studies were
synthesized in a narrative format.
Results
Search strategy yield
Initially, there were 25,911 hits gathered from databases and
secondary searches for the search dates defined in the
methods. After reviewing titles and abstracts, articles
not meeting inclusion criteria were removed. Full text
review left 99 eligible articles, after removal of
duplicates there were 8 studies from the updated review
Table 2. Assessment of the quality of the randomized trials (n= 13) using the PEDro scale.
Criteria 1 2 3 4 5 6 7 8 9 10 11 Total
Moseley (2002) Y Y Y Y N N Y Y Y Y Y 8/10
Moseley (2003c) Y Y Y Y N N Y Y N Y Y 7/10
Moseley et al. (2004) Y Y Y Y Y Y Y Y N Y Y 9/10
Ryan et al. (2010) Y Y Y Y N Y Y Y N Y Y 8/10
Meeus et al. (2010) Y Y Y Y Y N Y Y Y Y Y 9/10
Vibe Fersum et al. (2013) Y Y Y Y Y N Y N N Y Y 7/10
Gallagher et al. (2013) Y Y Y Y Y Y Y Y Y Y Y 10/10
Van Oosterwijck et al. (2013) Y Y Y Y Y N Y Y Y Y Y 9/10
Ittersum et al. (2014) Y Y Y Y N N Y N Y Y Y 7/10
Louw et al. (2014) Y Y Y Y Y N Y Y Y Y Y 9/10
Téllez-García et al. (2014) Y Y Y Y N N Y Y Y Y Y 8/10
Beltran-Alacreu et al. (2015) Y Y Y Y N N Y Y Y Y Y 8/10
Pires et al. (2015) Y Y Y Y N sN Y Y Y Y Y 8/10
Figure 1. Retrieval and review process.
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along with 5 eligible studies from previous review. This
systematic review is based on these 13 published RCTs
(Figure 1) (Beltran-Alacreu, Lopez-de-Uralde-Villanueva,
Fernandez-Carnero, and La Touche, 2015;Gallagher,
McAuley, and Moseley, 2013;Ittersumetal.,2014;Louw,
Diener, Landers, and Puentedura, 2014; Meeus et al., 2010;
Moseley, 2002,2003c; Moseley, Nicholas, and Hodges,
2004;Pires,Cruz,andCaeiro,2015;Ryan,Gray,Newton,
and Granat, 2010; Téllez-García et al., 2014;Van
Oosterwijck et al., 2013;VibeFersumetal.,2013). The
13 RCTs comprised 734 patients.
Critical appraisal
Hierarchy of evidence
All 13 published papers were RCTs.
Methodological quality
ThepaperswerereviewedagainstthePEDroscale.
Agreement was obtained between reviewers and com-
pared with the PEDro Database on each of the cri-
teriainthePEDroscalewithresultslistedinTable 2.
All the studies scored a 6/10 or higher on the PEDro
scale demonstrating good methodological quality.
The blinding of subjects and those that administered
the therapy were the most common criteria not met.
This is partially due to the face-to-face delivery style
of the intervention of PNE making it difficult to
blind the person providing and receiving the PNE.
Educational content and delivery methods
Naming the intervention
The original systematic review (Louw, Diener, Butler,
and Puentedura, 2011)reportedonthevarious
names given to the educational intervention of
explaining the biology of the pain experience to the
patient with the aim at reducing pain and disability.
The continued variation in the interventional name
used by the various authors continues: (1) pain neu-
rophysiology education (Pires, Cruz, and Caeiro,
2015); (2) therapeutic patient education (Beltran-
Alacreu, Lopez-de-Uralde-Villanueva, Fernandez-
Carnero, and La Touche, 2015); (3) neuroscience
education (Téllez-García et al., 2014); (4) pain
physiology education (Meeus et al., 2010; Moseley,
2003c;VanOosterwijcketal,2013); (5) Pain neu-
roscience education (Ittersum et al, 2014;Louw,
Diener, Landers, and Puentedura, 2014); (6) neuro-
physiology education (Moseley, Nicholas, and
Hodges, 2004); (7) pain biology education (Ryan,
Gray, Newton, and Granat, 2010); and (8) neurophy-
siology of pain education (Moseley, 2002).
Two studies did not directly call the educational
intervention a specific name but were a part of a book
of metaphors and stories to help understand the
biology of pain (Gallagher, McAuley, and Moseley,
2013) and the cognitive component of the education
intervention (Vibe Fersum et al., 2013).
Patient characteristics
There were 734 subjects in the reviewed manuscripts
with 398 of them receiving PNE (70% female). The
mean age of subjects receiving educational intervention
was 41.7 years (calculated from the means of the mean
reported ages from each study). The youngest cohort
had a mean age of 24 ± 10 years (Moseley, Nicholas,
and Hodges, 2004) and the oldest cohort had 50.9 ± 6.2
years (Pires, Cruz, and Caeiro, 2015). PNE was utilized
for multiple pain conditions: low back pain, chronic
fatigue syndrome, fibromyalgia, lumbar radiculopathy
awaiting lumbar surgery, and chronic neck pain.
Content of therapeutic neuroscience education
Specific content of each of the educational sessions can
be found in Table 3. Summary of the PNE content were
Neurophysiology of pain (Beltran-Alacreu, Lopez-
de-Uralde-Villanueva, Fernandez-Carnero, and La
Touche, 2015; Gallagher, McAuley, and Moseley,
2013; Ittersum et al., 2014; Louw, Diener, Landers,
and Puentedura, 2014; Meeus et al., 2010;
Moseley, 2002,2003c; Moseley, Nicholas, and
Hodges, 2004; Pires, Cruz, and Caeiro, 2015;
Ryan, Gray, Newton, and Granat, 2010; Van
Oosterwijck et al., 2013; Vibe Fersum et al., 2013)
No reference of anatomic or patho-anatomic
models (Moseley, 2002,2003c; Moseley, Nicholas,
and Hodges, 2004; Téllez-García et al., 2014)
No discussion of the emotional or behavioral
aspects of pain (Moseley, 2003c; Moseley,
Nicholas, and Hodges, 2004)
Nociception and nociceptive pathways (Gallagher,
McAuley, and Moseley, 2013; Ittersum et al., 2014;
Louw, Diener, Landers, and Puentedura, 2014;
Moseley, 2003c; Moseley, Nicholas, and Hodges,
2004; Pires, Cruz, and Caeiro, 2015; Téllez-García
et al., 2014)
Synapses (Moseley, 2003c; Moseley, Nicholas, and
Hodges, 2004)
Action potentials (Louw, Diener, Landers, and
Puentedura, 2014)
Spinal inhibition and facilitation (Gallagher,
McAuley, and Moseley, 2013; Moseley, 2003c;
Van Oosterwijck et al., 2013; Vibe Fersum et al.,
2013)
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Table 3. Participants, interventions, and outcomes in the reviewed studies.
Participants Interventions Outcomes
Author n
Sample
characteristics Diagnostic criteria Treatment Control
Outcome
instruments Time of assessment
Moseley (2002)57
LBP > 2
months
Women =
59%
Age (years):
EG* 43 ± 7
and CG** 38 ±
7
Duration of
symptoms
(months): EG
= 39 ± 18 and
CG 37 ± 12
NA Two physiotherapy sessions per week for 4
weeks; manual therapy including mobilization
and manipulation, soft tissue massage, muscle
and neural-mobilization techniques, but no
electrophysical modalities; specific trunk
stabilization program; maintain home
exercises indefinitely; 1 hour educational
session once a week for 4 weeks; one-on-one
education format by an independent
therapist; content = neurophysiology of pain
with no reference to lumbar spine;
accompanied by workbook with one page of
revision material and three comprehensive
exercises per day for 10 days
Ongoing medical care as advised by their
general practitioner.
No attendance of physiotherapy
Numeric rating
scale (NRS);
meaningful dif-
ference set at 2
points
Roland Morris
Disability
Questionnaire
(RMDQ); mean-
ingful difference
set at 4 points
Numbers needed
to treat (NNT)
Baseline, 1 month after
intervention and 1 year
after intervention
Moseley (2003c)41
LBP > 3
months
Women = EG
67% and CG =
60%
Age (years):
EG = 40 ± 7
years and CG
= 42 ± 7 years
Duration of
symptoms
(months): EG
= 33 ± 11 and
CG = 30 ± 14
NA Individual 4 × 1 hour educational session on
the physiology of pain and injury by a
physiotherapist; additionally received two
physiotherapy sessions per week for 4 weeks
focusing on spinal stabilization exercises
Group session involved a single 4-hour session
with a group of 710 patients provided by a
physiotherapist; physiology of pain and injury;
additionally received two physiotherapy
sessions per week for 4 weeks focusing on
spinal stabilization exercises
Numeric rating
scale (NRS)
Roland Morris
Disability
Questionnaire
(RMDQ)
Numbers needed
to treat (NNT)
Baseline, 1 month
following ongoing
medical treatmentand 1
month and 2 months after
educational and
physiotherapy sessions
(Continued )
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Table 3. (Continued).
Participants Interventions Outcomes
Author n
Sample
characteristics Diagnostic criteria Treatment Control
Outcome
instruments Time of assessment
Moseley et al. (2004)58
LBP > 6
months
Age (years):
EG = 24 ± 10
and CG = 45
±6
Duration of
pain (months):
EG = 18 ± 11
and CG = 20
±11
NA Education session by a physiotherapist in one-
to-one seminar format; session lasted 3 hours;
diagrams and hypothetical examples used as
teaching tools; at conclusion: workbook with
10 sections; patients asked to read one
section per day and answer three questions
on each session
Neurophysiology Education
No specific application was made to the lower
back, or to emotional and behavioral patterns
commonly associated with chronic pain such
as catastrophic thought processes or fear
avoidance
The Nervous System
Presentation of the basic structure of the
nervous system, with a focus on the
components of the nociception/pain
pathways; this section included an outline of
the functional significance of each component
Synapses
Presentation of how nerves talk to each
other,including the concept of chemicals
(neurotransmitters), postsynaptic receptors,
and a conceptual volume knob
(postsynaptic excitation and inhibition), with a
special focus on the danger messenger
nerve(second order nociceptive neuron)
Plasticity of the Nervous System
The adaptability of the nervous system
including: afferent and efferent pathways; the
variable state of neural structures including
normal state, peripheral, and central
sensitization; receptor synthesis; axonal
sprouting; the neural response to inactivity;
and movement control
Education session by a physiotherapist in one-
to-one seminar format; session lasted 3 hours;
diagrams and hypothetical examples used as
teaching tools; at conclusion: workbook with
10 sections; patients asked to read one
section per day and answer three questions
on each session
Back Education
Anatomy and physiology of the bones and
joints of the lumbar spine; the intervertebral
disc; the trunk and back muscles; normal
spinal curves; posture and movements,
including analysis of postures and activities
according to intra-discal pressures and joint
forces; lifting techniques and lifting loads;
lifting aids and ergonomics advice; principles
of stretching; and strength, endurance, and
fitness training
It did not include information about the
nervous system, except for outlining the
location and course of the spinal cord and the
spinal nerve roots; it was similar to education
material that has been researched elsewhere
and the education components of back
schools and functional restoration programs
Roland Morris
Disability
Questionnaire
(RMDQ)
Brief Survey of
Pain Attitudes
(revised) (SOPA
(R))
Pain
Catastrophization
Scale (PCS)
Straight Leg
Raise (SLR)
(inclinometer)
Forward Bending
Range (Distance
from longest fin-
ger to floor)
Abdominal Draw
In Task (ADIT)
Pre-treatment, 3 weeks
(Continued )
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Table 3. (Continued).
Participants Interventions Outcomes
Author n
Sample
characteristics Diagnostic criteria Treatment Control
Outcome
instruments Time of assessment
Ryan et al. (2010)38
LBP > 3
months
Education group
n=18
11 women
Age (years) =
45.5 ± 9.5
Duration of
pain (months)
= 13.7 ± 10.2
Education and
Exercise group
n=20
14 women
Age (years)
45.2 ± 11.9
Duration of
pain (months)
= 7.6 ± 7
NA Pain Biology Only
A 2.5-hour pain biology education session
Cognitive behavioral intervention focused on
reshaping the participants beliefs and
attitudes about their back pain, attempting to
decrease fear avoidance and harm beliefs,
increase self-efficacy, and decrease avoidance
behavior
The biology of pain
Verbal communication, prepared diagrams
and free-hand drawings Additionally, all
participants received The Back Book
Pain Biology and Exercise
A 2.5- hour pain biology education session
Cognitive behavioral intervention focused on
reshaping the participants beliefs and
attitudes about their back pain, attempting to
decrease fear avoidance and harm beliefs,
increase self-efficacy, and decrease avoidance
behavior
The biology of pain
Verbal communication, prepared diagrams
and free-hand drawings
Additionally, all participants received The
Back Book
Exercise component
Back to Fitness exercise classes; six classes,
one a week for 6 weeks; the classes involved
circuit-based, graded, aerobic exercises with
some core stability exercises
The classes involved a warm-up phase (10
minutes), an aerobic phase (2030 minutes),
and a warm-down phase (1015 minutes); the
aerobic phase involved circuit-based exercise;
for most exercises, there was an easy,
moderate, and hard version, and the
participant could choose which version to
perform
Roland Morris
Disability
Questionnaire
(RMDQ)
Numeric Rating
Scale (NRS)
Repeated sit-to-
stand test
The 50-foot walk
test
5-minute walk
test
Tampa Scale of
Kinesiophobia
(TSK-13)
Pain Self-Efficacy
Questionnaire
(PSEQ)
Step count
(activPALactiv-
ity monitor)
Pre-treatment and 8 weeks
later, 3 months later
Meeus et al. (2010)46
Chronic fati-
gue syndrome
and wide-
spread pain
Women: EG =
22 and CG =
18
Age (years):
EG = 38.3 ±
10.6 and CG =
42.3 ± 10.2
1994 Centers for
Disease Control
and Prevention
criteria for CFS
(Fukuda et al.,
1994)
Pain Physiology
One 30-minute interactive session
Physiology of the nervous system in general
and of the pain system in particular
The theoretic information was illustrated with
pictures and examples
The objective of the education was to teach
patients the function, mechanisms, and
modulation of (chronic) pain, and so forth
Pacing and Self-Management
One 30-minute interactive session; pacing and
self-management education was provided to
all participants in the control group; pacing is
a strategy in which patients are encouraged
to achieve an appropriate balance between
activity and rest in order to avoid
exacerbation and to set realistic goals for
increasing activity; following this energy
management strategy, patients should avoid
activities at an intensity that exacerbates
symptoms, or they should intersperse
activities with periods of rest
Neurophysiology
of Pain Test
Pain
Catastrophization
Scale (PCS)
Pain Coping
Inventory (PCI)
Tampa Scale of
Kinesiophobia
(TSK)
Pain Threshold
Assessment
(Fisher
algometer)
Pre-treatment and
immediately post-
treatment
(Continued )
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Table 3. (Continued).
Participants Interventions Outcomes
Author n
Sample
characteristics Diagnostic criteria Treatment Control
Outcome
instruments Time of assessment
Vibe Fersum et al.
(2013)
94 Non-specific
low back pain
>3 months
Classification-
based Cognitive
Functional
Therapy group
(CB-CFT)
27 women
and 24 men
Age (years):
41.0 ± 10.3
Manual Therapy
and Exercise
group (MT-EX)
21 women
and 22 men
Age (years):
42.9 ± 12.5
NA CB-CFT group
A cognitive component based on findings
from Orebro Musculoskeletal Pain
Questionnaire
Specific movement exercises as directed by
the movement classification
Targeted functional integration of activities in
daily life
Physical activity program tailored to the
movement classification; initial session of 1
hour, follow-ups 3045 minutes; patients seen
weekly for first 23 weeks and then
progressed to one session ever 23 weeks for
12-week intervention period; mean number of
treatments 7.7 (range 416; SD 2.6)
MT-EX group
Joint mobilization or manipulation techniques
to spine or pelvis best on current manual
therapy practice; general exercise of motor
control exercises; motor control exercises
involving isolated contractions of deep
abdominal muscles in different functional
positions; initial session, 1 hour, follow-ups, 30
minutes; mean number of treatments 8.0
(range 317; SD 2.9)
Primary outcome
measures
Oswestry
Disability Index
(ODI)
Pain Intensity
Numeric Rating
Scale (PINRS)
Secondary outcomes
Hopkins
Symptoms
Checklist (HSCL-
25)
Fear-Avoidance
Belief
Questionnaire
(FABQ)
Total lumbar
spine range of
motion
Patient
satisfaction
Sick-leave days
Care-seeking
Baseline, post 12-week
intervention and 12
months post-intervention
(Continued )
PHYSIOTHERAPYTHEORYANDPRACTICE 9
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Table 3. (Continued).
Participants Interventions Outcomes
Author n
Sample
characteristics Diagnostic criteria Treatment Control
Outcome
instruments Time of assessment
Gallagher et al.
(2013)
79 Pain sufficient
to disrupt
activities of
daily living for
> than pre-
vious 3
months
Metaphors group
n= 40 (26
female)
Age (years):
42 ± 11
Duration of
pain (months):
25 ± 19
Advice group
n= 39 (22
female)
Age (years):
45 ± 11
Duration of
pain (months):
31 ± 20
NA Booklet 1
Metaphors and stories to help understand the
biology of pain
Material from Painful Yarns: 80 pages divided
in 11 sections
Readability on Gunning Fog Index was 7
Booklet 2
Advice about managing pain; material drew
from The Back Book and Manage Your Pain;80
pages divided in 11 sections; readability on
Gunning Fog Index was 8
Primary outcome
measures
Pain Biology
Questionnaire
(PBQ)
Pain
Catastrophizing
Scale (PCS)
Secondary outcomes
Pain (11-point
numeric scale)
Patient-Specific
Functional Scale
(PSFS)
Baseline, 3 weeks and 12
weeks
Control group cross-over:
15 weeks and 24 weeks
(Continued )
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Table 3. (Continued).
Participants Interventions Outcomes
Author n
Sample
characteristics Diagnostic criteria Treatment Control
Outcome
instruments Time of assessment
Van Oosterwijck et al.
(2013)
30 Fibromyalgia
Experimental
group
n= 15 (12
women)
Age (years):
45.8 ± 9.5
Duration of
onset
(months): 156
±96
Control group
n= 15 (14
female)
Age (years):
45.9 ± 11.5
Duration of
onset
(months): 116
±46
1990 American
College of
Rheumatology
(ACR) criteria
Experimental group received education on
pain neurophysiology; received in oral format
with written leaflet containing information
and encouraged to take home and read
several times; 1 week later second
intervention delivered over the phone
Control group received education on pacing
self-management techniques; received in oral
format with written leaflet containing
information and encouraged to take home
and read several times; 1 week later second
intervention delivered over the phone
Primary outcome
measures
Spatial summa-
tion procedures
(SSP)
Fibromyalgia
Impact
Questionnaire
(FIQ)
Medical
Outcomes Short
Form 36 Health
Status Survey
(SF-36)
Pain Coping
Inventory (PCI)
Pain
Catastrophizing
Scale (PCS)
Pain Vigilance
and Awareness
Questionnaire
(PVAQ)
Tampa Scale
Kinesiophobia
(TSK)
Neurophysiology
of Pain Test
Secondary outcomes
Pain Pressure
Threshold
Baseline, 2 weeks, 3
months
(Continued )
PHYSIOTHERAPY THEORY AND PRACTICE 11
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Table 3. (Continued).
Participants Interventions Outcomes
Author n
Sample
characteristics Diagnostic criteria Treatment Control
Outcome
instruments Time of assessment
Ittersum et al. (2014) 105 Fibromyalgia
Pain
Neuroscience
Education group
n= 53 (50
female)
Age (years):
47.6 ± 9.1
Illness dura-
tion (years):
8.5
Relaxation
Education group
n= 52 (48
female)
Age (years):
45.8 ± 9.8
Illness dura-
tion (years):
8.0
American College
of Rheumatology
(ACR) criteria
Pain Neuroscience Education received an
educational booklet with written and
illustrated information on pain physiology and
the mechanisms of central sensitization;
educational booklet explained structure and
function of nervous system and difference
between nociception and pain; central
sensitization is introduced as hypersensitivity
of the nervous system through metaphor;
explained factors at onset and maintenance of
central sensitization; three case examples
used to explain how to use this information in
daily life; booklet of 15 pages, and
encouraged to read several times; received
follow-up supporting telephone call 2 weeks
post receiving information
Relaxation education group received written
information on relaxation exercise and
instructions on how to perform such exercises;
Loesers model of pain used to briefly explain
physical and psychological factors with
chronic pain; booklet 15 pages, and
encouraged to read several times and apply
information in daily life; received follow-up
supporting telephone call 2 weeks post
receiving information
Primary outcome
measures
Fibromyalgia
Impact
Questionnaire
(FIQ)
Secondary outcomes
Revised Illness
Perception
Questionnaire for
FM (IPQ-R_FM)
Pain
Catastrophizing
Scale (PCS)
Patient opinions
about the book-
let on six-point
Likert scale
Baseline, 6 weeks, 6
months follow-up
Louw et al. (2014) 67 Patients with
lumbar
radiculopathy
scheduled for
lumbar surgery
Experimental
group
n=32
Age (years):
49.59
Duration of
symptoms
(days): 91.41
Control group
n=35
Age (years):
49.65
Duration of
symptoms
(days): 92.29
NA Pre-operative neuroscience education (NE)
covered: (1) decision to have lumbar surgery;
(2) nervous system physiology and pathways;
(3) peripheral nerve sensitization; (4) surgical
experiences and environmental issueseffects
on nerve sensitivity; (5) calming the nervous
system; (6) recovery after lumbar surgery; (7)
scientific evidence; (8) reflection and writing
questions for surgeon prior to surgery. NE
provided by physical therapist in one-on-one
session averaging 30 minutes using pictures,
examples, metaphors, and drawings; patients
were given booklet that summarized
educational session information and asked to
read at least once before surgery; patients
also received usual careregarding
preoperative education from surgeon and
staff
Usual careregarding preoperative education
from respective surgeon and staff
Primary outcome
measures
Numeric Pain
Rating Scales
(NPRS)
Oswestry
Disability Index
(ODI)
Secondary outcomes
Thoughts/beliefs
about surgery
numeric scale (1
10)
Healthcare utili-
zation questions
Baseline, 1, 3, 6, and 12
month(s)
(Continued )
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Table 3. (Continued).
Participants Interventions Outcomes
Author n
Sample
characteristics Diagnostic criteria Treatment Control
Outcome
instruments Time of assessment
Téllez-García et al.
(2014)
12 Chronic non-
specific low
back pain
TrP-DN group
n=6(4
female)
Age (years):
37 ± 13
Time with
pain (months):
19 ± 8
TrP-DN+EDU
group
n=6(4
female)
Age (years):
36 ± 5
Time with
pain (months):
17 ± 9
NA Neuroscience education group (TrP-DN +
EDU) received 30-minute education session,
once per week for the last two sessions
(treatment session 2 and 3) after TrP-DN
treatment (as performed in control group);
face-to-face individual instruction on
neurophysiology of pain with no particular
reference to the lumbar spine; informed about
the role of beliefs and attitudes toward their
pain; PowerPoint presentation based on
Explain Pain was used; during the session,
patients were encouraged to ask questions to
individualize information; written information
about pain physiology concepts were
provided as homework between sessions
Clinician with 10 years experienced in
technique delivered trigger point-dry needling
(TrP-DN) done to active trigger points in
gluteus medius and quadratus lumborum;
position was side lying, with depth of needle
insertion approximately 2025 mm and
moved in multi-directions until first local
twitch response was obtained; needling
performed with up and down movement
58 mm with no rotation at approximately 1
Hz for 2530 seconds; treatment done one
time per week over 3 weeks
Primary outcome
measures
RolandMorris
Disability
Questionnaire
(RMDQ)
Oswestry Low
Back Pain
Disability Index
(ODI)
Numerical Pain
Rate Scale (NPRS)
Tampa Scale of
Kinesiophobia
(TSK)
Pressure pain
threshold (PPT)
Baseline, 1 week after last
intervention
(Continued )
PHYSIOTHERAPY THEORY AND PRACTICE 13
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Table 3. (Continued).
Participants Interventions Outcomes
Author n
Sample
characteristics Diagnostic criteria Treatment Control
Outcome
instruments Time of assessment
Beltran-Alacreu et al.
(2015)
45 Non-specific
chronic neck
pain
Experiment
group 1
n= 15 (13
female)
Age (years):
40.9 ± 16.2
Pain duration
(months): 54.9
± 57.1
Experiment
group 2
n= 15 (10
female)
Age (years):
39.8 ± 13.4
Pain duration
(months): 83.4
(94.1)
Control group
n= 15 (12
female)
Age (years):
43.5 ± 15.9
Pain duration
(months): 95.8
± 77.5
NA Experimental group 1 (Exp1)
Eight one-on-one sessions over 1 month;
same treatment as control group with
addition of pain neuroscience education in
two sessions; neuroscience education based
on biobehavioral approach divided into three
parts: cognitive, operant, and respondent;
neuroscience education duration was
approximately 20 minutes for each of two
sessions; first session on initial visit covering
cognitive part; use of PowerPoint with
diagrams, images, and texts with education
along with information booklet reviewing
relevant content of education from first
session; second session on fifth visit reviewing
first session and operant and respondent
parts. Operant section explained self-
treatment techniques and coping strategies to
reduce attention to pain.
Experimental group 2 (Exp2)
Received same intervention as Experimental
group 1 with addition of therapeutic exercise
program; exercise program based on neck
stabilization exercises for deep neck flexors
and extensors and neural self-mobilizations;
progressive exercise program was added in
sessions 58; with integration of exercise
treatment during treatment session manual
therapy, time was halved; patients asked to
perform exercises once per day at home
Eight one-on-one sessions over 1 month;
manual therapy techniques with specific
passive movements of cervical facet joints,
global mobilization of cervical spine and high-
velocity technique to dorsal spine
Primary outcome
measure
Neck Disability
Index (NDI)
Secondary outcomes
Tampa Scale of
Kinesiophobia
(TSK)
Fear Avoidance
Beliefs
Questionnaire
(FABQ)
Neck Flexor
Muscle
Endurance
(NFME) test
Visual Analog
Fatigue Scale
(VAFS)
Baseline, 4, 8, 16 weeks
Pires et al. (2015)62
Chronic low
back pain
Education group
n= 30 (20
female)
Age (years):
50.9 ± 6.2
Control group
n= 32 (20
female)
Age (years):
51.0 ± 6.3
NA Completed aquatic exercises program similar
to control with addition of pain
neurophysiology program; two group
sessions, 90 minutes each; topics addressed:
acute pain origin in nervous system, transition
from acute to chronic pain, central
sensitization, role of brain in pain perception,
cognitive and behavioral responses related to
pain, flare-up management and pacing;
metaphors and pictures used throughout the
session
Six-week program of 12 biweekly sessions of
aquatic exercise; groups of 69 participants
lasting 3050 minutes; three phases: (1)
warm-up; (2) specific exercises; (3) warm-
down
Primary outcome
measures
Visual Analogue
Scale (VAS)
Quebec Back
Pain Disability
Scale
Secondary outcomes
Tampa Scale of
Kinesiophobia
(TSK)
Baseline, 6 weeks after
beginning program and 3
months follow-up
*EG, experimental group; **CG, control group.
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Peripheral sensitization (Gallagher, McAuley, and
Moseley, 2013; Ittersum et al., 2014; Louw, Diener,
Landers, and Puentedura, 2014; Moseley, 2003c;
Van Oosterwijck et al., 2013; Vibe Fersum et al.,
2013)
Central sensitization (Gallagher, McAuley, and
Moseley, 2013; Ittersum et al., 2014; Louw,
Diener, Landers, and Puentedura, 2014; Moseley,
2003c; Moseley, Nicholas, and Hodges, 2004;
Pires, Cruz, and Caeiro, 2015; Vibe Fersum et al.,
2013)
Plasticity of the nervous system (Gallagher,
McAuley, and Moseley, 2013; Louw, Diener,
Landers, and Puentedura, 2014; Moseley, 2003c;
Moseley, Nicholas, and Hodges, 2004; Van
Oosterwijck et al., 2013)
Psychosocial factors and beliefs contributing to
pain (Beltran-Alacreu, Lopez-de-Uralde-Villanueva,
Fernandez-Carnero, and La Touche, 2015;
Gallagher, McAuley, and Moseley, 2013;Pires,Cruz,
and Caeiro, 2015; Téllez-García et al., 2014;Vibe
Fersum et al., 2013)
The book Explain Pain by Butler and Moseley (2003)
was directly referenced in six of the studies (Meeus
et al., 2010; Pires et al., 2015; Ryan, Gray, Newton,
and Granat, 2010; Téllez-García et al., 2014; Van
Oosterwijck et al., 2013).
Professionals performing PNE
Physical therapists have been the delivery professional
of PNE in all of the studies found in this review. In one
study, utilizing booklets, the lead author was an
occupational therapist, but no direct education (other
than the book, authored by a physical therapist) was
provided (Gallagher, McAuley, and Moseley, 2013).
Duration and frequency of PNE
The time and frequency of delivery was varied with
ashift toward shorter durations found more com-
mon in the more recent studies. Longest duration of
the documented sessions was 4 hours (Moseley,
2003c) in one session, with shortest duration being
around 30 minutes (Louw, Diener, Landers, and
Puentedura, 2014; Meeus et al., 2010;Téllez-García
et al., 2014;VanOosterwijcketal.,2013). Shortest
frequency was one time educational session
(Moseley, Nicholas, and Hodges, 2004;Pires,Cruz,
and Caeiro, 2015) with other studies utilizing edu-
cation spread out over multiple episodes during the
course of treatment.
Educational format and tools
The primary format for delivery of PNE was verbal
one-on-one between patient and provider; two studies
utilized group sessions (Moseley, 2003c; Pires, Cruz,
and Caeiro, 2015) and one study did not have any
face-to-face contact and only the information from a
book that was read by the subjects (Gallagher,
McAuley, and Moseley, 2013). The one-on-one
sessions were most often described in terms of con-
versational, with encouragement for subjects to ask
questions, so material could be individualized and
not a straight lecture format. Various teaching aids
were used during the delivery of the education con-
sisting of prepared pictures, PowerPoint presentations,
drawings, examples, metaphors, and books comple-
menting the in person education information.
Adjunct treatment to PNE
Different study methodologies were used in the studies
under review. The use of PNE was used in conjunction
with other active movement-based therapy interventions
in many of the studies. The list of other therapeutic
activities used with PNE consisted of:
Mobilization and manipulation (Moseley, 2002)
Soft tissue massage (Moseley, 2002)
Muscle and neural mobilization (Beltran-Alacreu,
Lopez-de-Uralde-Villanueva, Fernandez-Carnero,
and La Touche, 2015; Moseley, 2002)
Trunk stabilization (Moseley, 2002,2003c; Ryan,
Gray, Newton, and Granat, 2010)
Circuit-based aerobic exercise (Ryan, Gray,
Newton, and Granat, 2010)
Movement exercises (Vibe Fersum et al., 2013)
Paced/graded exposure with activities of daily
(Meeus et al., 2010; Vibe Fersum et al., 2013)
Trigger point dry needling (Téllez-García et al., 2014)
Neck stabilization exercises (Beltran-Alacreu,
Lopez-de-Uralde-Villanueva, Fernandez-Carnero,
and La Touche, 2015)
Aquatic exercise program (Pires, Cruz, and
Caeiro, 2015)
None (PNE only) (Ittersum et al., 2014; Louw, Diener,
Landers, and Puentedura, 2014; Moseley, Nicholas,
and Hodges, 2004;VanOosterwijcketal.,2013)
Outcome measures
Many different outcome measurement tools were used
across the studies (Table 3) and assessed at various time
points post-intervention. Measurements periods varied
from immediate post-intervention to 1 year follow-up.
We used the grouping of each of the outcomes
PHYSIOTHERAPY THEORY AND PRACTICE 15
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measurements into the four categories established in the
initial systematic review: pain, function, psychosocial
factors, and movement along with adding a fifth cate-
gory of healthcare utilization.
Outcomes related to pain
Pain rating (Numeric Pain Rating Scales or Visual
Analog Scale) (Gallagher, McAuley, and Moseley,
2013; Louw, Diener, Landers, and Puentedura,
2014; Moseley, 2002; Pires, Cruz, and Caeiro,
2015; Ryan, Gray, Newton, and Granat, 2010;
Vibe Fersum et al., 2013)
Pain knowledge (Neurophysiology of Pain
Questionnaire or Pain Biology Questionnaire)
(Meeus et al., 2010; Van Oosterwijck et al., 2013)
Pain Vigilance and Awareness Questionnaire (Van
Oosterwijck et al., 2013)
Pressure Pain Threshold (Meeus et al., 2010; Téllez-
García et al., 2014; Van Oosterwijck et al., 2013)
Spatial summation procedure (Van Oosterwijck
et al., 2013)
Outcomes related to function and disability
Roland Morris Disability Questionnaire (Moseley,
2002,2003c; Ryan, Gray, Newton, and Granat,
2010; Téllez-García et al., 2014)
Oswestry Disability Index (Louw, Diener, Landers,
and Puentedura, 2014; Téllez-García et al., 2014;
Vibe Fersum et al., 2013)
Neck Disability Index (Beltran-Alacreu, Lopez-de-
Uralde-Villanueva, Fernandez-Carnero, and La
Touche, 2015)
Fibromyalgia Impact Questionnaire (Ittersum
et al., 2014; Van Oosterwijck et al., 2013)
Revised Illness Perception Questionnaire for
Fibromyalgia (Ittersum et al., 2014)
Short Form 36 Health Status Survey (Van
Oosterwijck et al., 2013)
Quebec Back Pain Disability (Pires, Cruz, and
Caeiro, 2015)
Patient-Specific Functional Scale (Gallagher,
McAuley, and Moseley, 2013)
Outcomes related to psychosocial factors
Tampa Scale of Kinesiophobia (Beltran-Alacreu,
Lopez-de-Uralde-Villanueva, Fernandez-Carnero,
and La Touche, 2015; Meeus et al., 2010; Pires,
Cruz, and Caeiro, 2015; Van Oosterwijck et al.,
2013)
Pain Catastrophization Scale (Gallagher, McAuley,
and Moseley, 2013; Ittersum et al., 2014; Moseley,
Nicholas, and Hodges, 2004)
Pain Coping Inventory (Meeus et al., 2010; Van
Oosterwijck et al., 2013)
Survey of Pain Attitudes (revised) (Moseley,
Nicholas, and Hodges, 2004)
Pain Self-Efficacy Questionnaire (Ryan, Gray,
Newton, and Granat, 2010)
Hopkins Symptoms Checklist (Vibe Fersum et al.,
2013)
Fear Avoidance Beliefs Questionnaire (Beltran-
Alacreu, Lopez-de-Uralde-Villanueva, Fernandez-
Carnero, and La Touche, 2015; Vibe Fersum et al.,
2013)
Beliefs about surgery (Louw, Diener, Landers, and
Puentedura, 2014)
Outcomes related to movement
Straight leg range of motion (Moseley, Nicholas,
and Hodges, 2004)
Lumbar range of motion (Moseley, Nicholas, and
Hodges, 2004; Vibe Fersum et al., 2013)
Abdominal draw in task (Moseley, Nicholas, and
Hodges, 2004)
Repeated sit to stand test (Ryan, Gray, Newton,
and Granat, 2010)
50-foot walk test (Ryan, Gray, Newton, and
Granat, 2010)
5-minute walk test (Ryan, Gray, Newton, and
Granat, 2010)
Step count (Ryan, Gray, Newton, and Granat,
2010)
Neck flexor muscle endurance test (Beltran-
Alacreu, Lopez-de-Uralde-Villanueva, Fernandez-
Carnero, and La Touche, 2015)
Visual Analog Fatigue Scale (Beltran-Alacreu,
Lopez-de-Uralde-Villanueva, Fernandez-Carnero,
and La Touche, 2015)
Outcomes related to healthcare utilization
Healthcare center visits (Moseley, 2002)
Sick-leave days (Vibe Fersum et al., 2013)
Care-seeking (Vibe Fersum et al., 2013)
Healthcare utilization questions (Louw, Diener,
Landers, and Puentedura, 2014)
Effectiveness of PNE
Results could not be pooled for all the studies due to
the variability in outcome measurement tools and dif-
fering control groups. Results of outcomes are summar-
ized in Table 4.
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Table 4. Effectiveness of PNE on pain, disability, anxiety, and stress for MSK conditions.
Outcome
Moseley
(2002)
Moseley
(2003c)
Moseley
et al. (2004)
Ryan et al.
(2010)
Meeus
et al.
(2010)
Vibe Fersum
et al. (2013)
Gallagher
et al. (2013)
Van Oosterwijk
et al. (2013)
Ittersum
et al. (2014)
Louw
et al.
(2014)
Téllez-García
et al. (2014)
Beltran-Alacreu
et al. (2015)
Pires
et al.
(2015)
Decrease in pain ratings ++ + + 000+
Increase pain tolerance 0 + 0
Increase knowledge of pain + + +
Improve function and
disability
++ + 0+0+000+0
Decrease fear of movement 0 0 + 0 + + 0
Decrease pain
catastrophization
+++00
Develop strategies to cope
with pain
00
Develop healthy attitudes
regarding pain
+0+
Decrease anxiety and/or
depression symptoms
+
Improve physical
movement and
performance
+00 +
Decrease health care
utilization
++ +
+, positive effectiveness; 0, no effectiveness.
PHYSIOTHERAPY THEORY AND PRACTICE 17
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PNE addressing pain
Ten of the 13 studies evaluated the effect of PNE on
pain of the subjects.
(1) The mean improvement of pain at 1 month
was 1.5 on the NRS (95% CI: 0.72.3) for
those receiving the intervention over those in
the control group. This difference was shown
to have a significant treatment effect (p<
0.01) with a number needed to treat to gain
clinical significance at 3 (95% CI: 28). At 1
year follow-up, this difference maintained in
regards to improvement with pain 1.9 (95%
CI: 12.8) with number needed to treat of
2 (95% CI: 14) (Moseley, 2002).
(2) Significant decrease in pain on NRS from
5-week on-going usual treatmentto end of
4-week treatment intervention and 12-month
follow-up. Individual education group showed
treatment effect of 3.1 (95% CI: 1.84.2) on
NRS at conclusion of 4-week intervention and
group education group showed 2.7 (95% CI:
1.63.9) reduction on NRS. The difference
between pre-treatment and post-treatment
between independent and group treatment
was 1.0 (95% CI: 0.32.0) (Moseley, 2003c).
(3) There was a significant time and group
interaction from pre-test to post-1-month
follow-up for PNE group over control group
of exercise and traditional education group
with decrease in NRS. This difference leveled
off at the 3 months post-intervention time
measurement point (Ryan, Gray, Newton,
and Granat, 2010).
(4) Pressure pain threshold decreased in both
groups over time but no between-group
differences were found at the end of the
intervention. Significant difference in pain
neuroscience knowledge in experimental
group over control group (p< 0.001) was
found (Meeus et al., 2010).
(5) Both treatment groups showed significant
improvement with respect to improved pain
ratings with the PNE group showing statisti-
cally (p< 0.001) superior outcomes compared
with traditional therapy group at 3 and 12
months follow-up. The mean difference
between groups for 3 and 12 months, respec-
tively, for PINRS were 2.1 (95% CI: 2.71.4)
and 1.3 (95% CI: 2.10.5) (Vibe Fersum et al.,
2013).
(6) Analysis showed that both groups improved
over time in NRS but there was no significant
effect between groups in regards to pain with
reading either the PNE book or control book.
Increased knowledge about pain biology in
the experimental group over advice group
(p< 0.01) was seen with an effect size of
Cohen d= 1.7 (Gallagher, McAuley, and
Moseley, 2013).
(7) Spatial summation procedure showed no signif-
icant differences at 2 weeks post-intervention
with PNE compared with control, but there
was a significant difference at 3 months (p=
0.041). There was no significant difference in
pressure pain threshold or Pain vigilance and
Awareness Questionnaire between groups over
assessment periods. Neurophysiology of pain
test showed significant increase in response
with experimental group (p< 0.001) but not
control group (p=0.150) (Van Oosterwijck
et al., 2013).
(8) There was no significant effect for low back or
leg pain between PNE group and control
group over the 12-month time. Overall time
effects for decreased pain for both groups
were significant (p< 0.002). There was short
term (1 month follow-up) effect with signifi-
cant decrease in pain for low back and leg (p<
0.046) but plateaued over the 3, 6, and 12
months follow-up (Louw, Diener, Landers,
and Puentedura, 2014).
(9) No group interaction for pain intensity was
found between trigger point dry needling
group with PNE (3.6 (95% CI: 6.0 to
1.1)) or without PNE (4.2 (95% CI: 6.6
to 1.7)) but time interaction was found
significant for both groups (p< 0.002).
There was no group interaction differences
for pressure pain threshold measurements
but there was significant time interaction
post-treatment at all three measurement
points (Téllez-García et al., 2014).
(10) Statistical differences were found for overall
group interaction by time and also between-
group interaction at 3 months follow-up
favoring the PNE group but none at 6 weeks
follow-up on the visual analog scale. Visual
analog change at 3 months for education
group compared with control group was
25.4 ± 26.7 and 6.6 ± 30.7, respectively
(Pires, Cruz, and Caeiro, 2015).
PNE addressing function
Twelve of the 13 studies addressed function through
various functional measurement tools. Six studies
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looked at general functional improvement scores
through use of Roland Morris Disability
Questionnaire (RMDQ) (Moseley, 2002; Moseley,
Nicholas, and Hodges, 2004; Ryan, Gray, Newton, and
Granat, 2010; Téllez-García et al., 2014) or Short Form
36 Health Status Survey (SF-36) (Van Oosterwijck
et al., 2013). Eight of the studies used more specific
questionnaires based on diagnostic or functional status.
The diagnostic or specific functional measurement
tools used were (1) Oswestry Disability Index (ODI)
(Louw, Diener, Landers, and Puentedura, 2014; Téllez-
García et al., 2014; Vibe Fersum et al., 2013); (2) Neck
Disability Index (NDI) (Beltran-Alacreu, Lopez-de-
Uralde-Villanueva, Fernandez-Carnero, and La
Touche, 2015); (3) Patient-Specific Functional Scale
(PSFS) (Gallagher, McAuley, and Moseley, 2013); (4)
Fibromyalgia Impact Questionnaire (FIQ) (Van
Oosterwijck et al., 2013); (5) Revised Illness
Perception Questionnaire for Fibromyalgia (IPQ-
R_FM) (Ittersum et al., 2014); and (6) Quebec Back
Pain Disability Scale (Pires, Cruz, and Caeiro, 2015).
(1) Both groups improved in regards to disability
with mean improvement of the intervention
group over control of 3.9 points on the
RMDQ (95% CI: 2.05.8). With number
needed to treat of 2 (95% CI: 25) for the
RMDQ (Moseley, 2002).
(2) Between-group change favored the interven-
tion group with a mean effect of 2.4 (95% CI:
0.84.2) on the RMDQ (Moseley, 2003c).
(3) Experimental group improved in RMDQ by 2
points (95% CI: 0.43.6) compared with con-
trol group post-treatment (Moseley, Nicholas,
and Hodges, 2004).
(4) There was a non-significant trend toward a
more favorable outcome with experimental
group in improvement of RMDQ (p= 0.127)
(Ryan, Gray, Newton, and Granat, 2010).
(5) Both groups showed significant improvement
over time with treatment for ODI scores. The
group receiving PNE had a significant (p<
0.001) mean difference improvement of 9.7
(95% CI: 12.7 to 6.7) at 3 months and 8.2
(95% CI: 12.6 to 3.8) at 12 months compared
with the other group ODI score. The group
receiving PNE showed an overall ODI
improvement over 12 months of 13.7 (95% CI:
11.416.1; p<0.001) (Vibe Fersum et al., 2013).
(6) Both groups improved over time in regards
to disability as measured through PSFS, but
no differential effect between groups was
found (p= 0.07) (Gallagher, McAuley, and
Moseley, 2013).
(7) Significant between-group differences were
found in favor of experimental group for SF-
36 physical functioning (p= 0.046), general
health perceptions (p< 0.001), and vitality (p
= 0.047) subscores. A large effect size (Cohen
d) was found for the SF-36 health perceptions
scale (d=0.98). The remaining SF-36 sub-
scores and FIQ did not show significant
effects for between-group differences (Van
Oosterwijck et al., 2013).
(8) No significant effects were found between
groups for FIQ, and all effect sizes for FIQ
domains were small. Illness perception as
measured through IPQ-R_FM did not show
any statistically different effects between
groups (Ittersum et al., 2014).
(9) There was no significant between-group
interaction (p> 0.167), both groups showed
improvement over time in regards to function
as measured with ODI (p< 0.002) (Louw,
Diener, Landers, and Puentedura, 2014).
(10) ODI scores showed no significant group
interaction changes for ODI (p= 0.542) or
RMDQ (p= 0.111). There was a main effect
for time for both groups for ODI (p< 0.001)
and RMDQ (p< 0.001) (Téllez-García et al.,
2014).
(11) NDI showed significant improvement (p<
0.01) for both experimental groups compared
with control group at the 4, 8, and 16 weeks
follow-ups (Beltran-Alacreu, Lopez-de-
Uralde-Villanueva, Fernandez-Carnero, and
La Touche, 2015).
(12) Functional disability showed significant (p<
0.05) group by time interaction but no statisti-
cally significant between-groups difference at 6
weeks (p= 0.83) or 3 months (p=0.09).A
greater percent of participants in PNE reported
benefits from treatment for functional disability
at both measurement points with only the 3
months follow-up showing significant (p=
0.034) findings (Pires, Cruz, and Caeiro, 2015).
PNE addressing psychosocial factors
Outcomes related to psychosocial factors were mea-
sured in 11 of the 13 studies. Researchers choose a
mixture of validated tests consisting: (1) Pain
Catostrophizing Scale (PCS) (Gallagher, McAuley, and
Moseley, 2013; Ittersum et al., 2014; Meeus et al., 2010;
Moseley, Nicholas, and Hodges, 2004; Van Oosterwijck
PHYSIOTHERAPY THEORY AND PRACTICE 19
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et al., 2013); (2) Pain Coping Index (PCI) (Meeus et al.,
2010; Van Oosterwijck et al., 2013); (3) Tampa Scale of
Kinesiophobia (TSK) (Beltran-Alacreu, Lopez-de-
Uralde-Villanueva, Fernandez-Carnero, and La
Touche, 2015; Meeus et al., 2010; Pires, Cruz, and
Caeiro, 2015; Ryan, Gray, Newton, and Granat, 2010;
Téllez-García et al., 2014; Van Oosterwijck et al., 2013);
(4) Pain Self-Efficacy Questionnaire (PSEQ) (Ryan,
Gray, Newton, and Granat, 2010); (5) Fear Avoidance
Beliefs Questionnaire (FABQ) (Beltran-Alacreu, Lopez-
de-Uralde-Villanueva, Fernandez-Carnero, and La
Touche, 2015; Vibe Fersum et al., 2013); (6) Survey of
Pain Attitudes (revised) (SOPA(R)) (Moseley, Nicholas,
and Hodges, 2004); (7) Hopkins Symptoms Checklist
(HSCL-25) (Vibe Fersum et al., 2013); and (8) Beliefs
about surgery questionnaire (Louw, Diener, Landers,
and Puentedura, 2014).
(1) Both SOPA(R) and PCS were better in the
experimental group compared with control
group (p< 0.001 for both). Effect size for
SOPA(R) total was 9.0 (95% CI: 6.511.5)
and for PCS was 6.0 (95% CI: 3.88.2)
(Moseley, Nicholas, and Hodges, 2004).
(2) No statistically significant effect for PSEQ or
TSK-13 was found (Ryan, Gray, Newton, and
Granat, 2010).
(3) Significant reduction (p= 0.009) in PCS for
ruminating scale in the PNE group compared
with control, coping strategies (PCI) trended
toward significance with distraction(p=
0.021) and worrying (p= 0.011). The TSK
did not reach significance levels when com-
paring groups (Meeus et al., 2010).
(4) FABQ for physical subscales showed significant
changes favoring experimental group at 3
months: 3.6 (95% CI: 5.3 to 1.9; p< 0.001)
and at 12 months 4.7 (95% CI: 6.5 to 3.0; p<
0.001). Work subscale of the FABQ also
showed favorable results toward experimental
group at both time measurement intervals
5.7
(95% CI: 7.8 to 3.6; p< 0.001) and 5.6 (95%
CI: 8.7 to 2.5, p<0.001),respectively.The
HSCL-25 also showed significant results at
3months:0.12 (95% CI: 0.19 to 0.04) and
at 12 months: 0.13 (95% CI: 0.22 to 0.04) in
favor of the experimental group (Vibe Fersum
et al., 2013).
(5) A large significant shift (p< 0.01) in PCS
scores was found in pain metaphor group
compared with control advice group initially
and at 3 months follow-up, with large effect
size at 3 months follow-up (Cohen d= 0.7).
When the control group was crossed over to
metaphor group, it also showed significant
(p< 0.01) improvements in PCS (Gallagher,
McAuley, and Moseley, 2013).
(6) Mean scores of PCI and TSK decreased with
treatment as they did not reach significance for
between-group differences (Van Oosterwijck
et al., 2013).
(7) In regards to PCS, there were no between-
group or within-group changes found
(Ittersum et al., 2014).
(8) Main effect for more favorable post-operative
opinion in experimental group over control
group was found on three questions: fully
prepared for surgery(p= 0.01), preopera-
tive education prepared well(p= 0.001), and
met expectations(p= 0.042) (Louw, Diener,
Landers, and Puentedura, 2014).
(9) Treatment with PNE had greater reduction (p
= 0.008) of kinesiophobia than those treated
without PNE. Between-group change was in
favor of PNE on TSK (12.7 (95% CI: 21.3
to 4.0)) (Téllez-García et al., 2014).
(10) With TSK there were significant effects (p<
0.05) for post-treatment, 8 and 16 weeks
for favoring experimental 1 to control. Also,
similar significant effects of TSK favoring
experimental 2 versus control at 8 and 16
weeks were found. There were no differences
in TSK when comparing the two experimental
groups. Effect size of experimental group 1 for
TSK was d= 1.22, while it was d= 1.02 for
experimental group 2. Significance (p< 0.5) for
FABQ was similarly in favor of experimental
group 1 and 2 over control with difference
between the two experimental groups. Effect
size for experimental 1 was d= 0.78 and for
experimental 2 was d= 1.13 (Beltran-Alacreu,
Lopez-de-Uralde-Villanueva, Fernandez-
Carnero, and La Touche, 2015).
(11) No statistical interaction was found with TSK
(Pires, Cruz, and Caeiro, 2015).
PNE addressing movement
Four of the studies looked specifically at an impairment
in movement. All four studies chose different physical
performance tasks to study effects.
(1) Forward bending and straight leg raise were
improved more in the experimental group
over the control group (p< 0.001 for both).
Abdominal drawing-intask did not show
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between-group differences (Moseley, Nicholas,
and Hodges, 2004).
(2) Physical performance measurements of
repeated sit-to-stand test, 50-foot walk test,
and 5-minute walk test did not show any sig-
nificant changes between the experimental and
control group (Ryan, Gray, Newton, and
Granat, 2010).
(3) No significant changes between the experimen-
tal and control group were found at 3 months
(Vibe Fersum et al., 2013).
(4) Visual Analog Fatigue Scale (VAFS) and Neck
Flexor Muscle Endurance Test (NFME) showed
significant effects (p< 0.05) at 8 and 16 weeks
follow-up. Experimental group 1 was signifi-
cant (p< 0.01) for VAFS and NFME. In experi-
mental group 2, the NFME test was significant
(p< 0.01) but not for VAFS (Beltran-Alacreu,
Lopez-de-Uralde-Villanueva, Fernandez-
Carnero, and La Touche, 2015).
PNE addressing healthcare utilization
Three studies explored changes in healthcare utilization
following PNE. Each study utilized different outcome
measurements for their study design.
(1) At 1 year followup, experimental group made
3.6 ± 2 (mean ± SD) healthcare center visits for
low back pain, which was statistically less (p<
0.001) than the control group who made 13.2 ±
5 visits (Moseley, 2002).
(2) Reduction of sick-leave days extracted from the
Orebro Screening Questionnaire was observed
with significance (p< 0.01) toward the experi-
mental group (z= 2.95). Also improved (p<
0.001) reduction in care-seeking after interven-
tion was noticed (z= 4.79) (Vibe Fersum et al.,
2013).
(3) Overall reduction in healthcare costs for med-
ical treatment at 1 year follow-up was less for
experimental group (mean = $22678.57, SD =
$3135.30) compared with control group (mean
= $4833.48, SD = $3256.00) (z=2.700, p=
0.007) (Louw, Diener, Landers, and
Puentedura, 2014).
Discussion
The results of this updated systematic review of PNE
for MSK pain provide supporting evidence for PNE
improving pain ratings, pain knowledge, disability,
pain catastrophization, fear-avoidance, attitudes and
behaviors regarding pain, physical movement, and
healthcare utilization (Ezzo et al., 2000; Fernández-de-
las-Peñas et al., 2006). These positive results need,
however, to be considered in lieu of the heterogeneous
nature of the studies included in this systematic review.
It is also important to recognize that no PNE study
showed any outcome to be worse than the control
groups, thus implying a significant riskbenefit ratio
in favor of PNE. In comparison with the previous two
systematic reviews, however, the quality of the studies,
number of studies, and total number of patients (n=
734) are substantially increased (Clarke, Ryan, and
Martin, 2011; Louw, Diener, Butler, and Puentedura,
2011). This increase not only reflects the increased
activity in this field of study but also impacts the
conclusions that can be made in regards to the efficacy
of PNE. For example, in the systematic review by Louw,
Diener, Butler, and Puentedura (2011) which included
lower-level studies (pseudo-RCT, casecontrol), the
efficacy of PNE addressing pain was reported as com-
pelling,whereas the current review using higher-level
RCTs showcases a similar and even increased effect on
reducing pain ratings.
Various noteworthy observations can be made. First,
only three studies reported 1 year outcomes, and inter-
estingly, also reported on healthcare utilization (Louw,
Diener, Landers, and Puentedura, 2014; Moseley, 2002;
Vibe Fersum et al., 2013). All three studies showed a
significant reduction of healthcare utilization 1 year
after PNE. Given the various concerns regarding
healthcare cost in general, there is an ever-increasing
request for treatments that are cheaper, easily accessi-
ble, and have long-lasting efficacy. Pain is complex, and
with well-documented issues such as central sensitiza-
tion, neuroplasticity, changes in endogenous mechan-
isms, etc., using pain ratings alone as a measure of
improvement seems illogical. Even though evidence
supports the reduction over time of pain with the
utilization of PNE, a sudden, total resolution of pain
is biologically questionable. The concept of reconcep-
tualizing pain, a cornerstone of PNE, aims to have
patients see their pain differently. This implies that
even though they still experience pain, they think
differently about it, equating it to sensitization of the
nervous system versus the health of the tissues.
Furthermore, this reconceptualization imparts a mes-
sage of despite the pain,it is worthwhile to move,
exercise, engage, and continue in daily activities and
not necessary to seek additional care for the sensitiza-
tion (pain). This behavior change is the key to changing
any patients healthcare status, that is, smoking, weight
gain, etc. In line with the results from this systematic
review and the three RCTs being discussed, it is argued
PHYSIOTHERAPY THEORY AND PRACTICE 21
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that true behavior change is reflected in healthcare
utilization. Given the relative low cost of onlyeduca-
tional sessions with a physical therapist, the ability to
have such a huge impact, especially 1 year, out needs
mention. In contrast, these three studies also highlight
the need for more long-term studies on the efficacy of
PNE to measure its true impact. To date, the authors
are only aware of one PNE study extending beyond 1
year outcome, with Louw, Diener, Landers, and
Puentedura (2014) measuring 3-year outcomes of
preoperative PNE for patients undergoing surgery for
lumbar radiculopathy.
The second observation highlights the possible differ-
ences between education-only approaches of PNE versus
PNE combined with a movement-based strategy such as
exercise and/or manual therapy. In five studies, patients
received education-only intervention (Gallagher,
McAuley, and Moseley, 2013; Ittersum et al., 2014;
Louw, Diener, Landers, and Puentedura, 2014;
Moseley, Nicholas, and Hodges, 2004; Van Oosterwijck
et al., 2013). None of these studies had any ability to
decrease pain ratings, whereas five of the six studies that
combined PNE with a physical intervention were able to
produce a significant reduction in pain ratings. In line
with the definition of PNE and the argument that PNE
biologizespain, teaching patients about the biology
and physiology of a pain experience would make sense.
Education-alone may not be sufficient for change. This is
important as many clinicians may be under the impres-
sion that PNE is education-only intervention.
Additionally, it has been reported that some clinicians
see PNE and pain science as hands-offversus hands-
on.This review strongly suggests that the combination
of PNE with movements, be it passive and/or active, may
be a key in the success of PNE. Further studies are
needed to explore this finding.
Various issues in regards to questions and potential
future avenues associated with PNE research are found
in the results of this systematic review. The obvious
shortcoming is the heterogonous studies regarding
design, patient populations, outcome measures, educa-
tional delivery methods, etc. By standardization of these
factors, subsequent reviews and meta-analysis may shed
further light on the efficacy of PNE. An interesting
observation is that three studies examined and showed
an increase in pain knowledge, yet this increased
knowledge of pain has yet to be shown to correlate to
decreased pain and disability. Of the three studies that
reported increased knowledge of pain, it is, however,
interesting to note that both Meeus et al. (2010) and
Gallagher, McAuley, and Moseley (2013) showed an
increase in pain knowledge as well as a positive effect
of their PNE on pain catastrophization. This increase of
pain knowledge and its potential effect warrants further
investigation. Additionally, in line with current trends
of MSK pain treatments, such as low back pain, is there
a need to explore sub-grouping of patients? Both
groups made meaningful changes in regards to various
outcome measures. Apart from PNE alone not being
effective in reducing pain ratings, the current review
does not show any meaningful trends beyond this and
warrants further investigation.
Conclusion
Strong evidence supports the use of PNE for MSK
disorders in reducing pain ratings, limited knowledge of
pain, disability, pain catastrophization, fear-avoidance,
unhealthy attitudes and behaviors regarding pain, limited
physical movement and healthcare utilization (Ezzo et al.,
2000; Fernández-de-las-Peñas et al., 2006).
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of the paper.
References
Beltran-Alacreu H, Lopez-de-Uralde-Villanueva I, Fernandez-
Carnero J, La Touche R 2015 Manual therapy, therapeutic
patient education, and therapeutic exercise, an effective
multimodal treatment of nonspecific chronic neck pain: A
randomized controlled trial. American Journal of Physical
Medicine and Rehabilitation 94(10 Suppl 1): 887897.
Bernard AM, Wright SW 2004 Chronic pain in the ED.
American Journal of Emergency Medicine 22: 444447.
Brox JI, Storheim K, Grotle M, Tveito TH, Indahl A, Eriksen
HR 2008 Systematic review of back schools, brief educa-
tion, and fear-avoidance training for chronic low back
pain. Spine Journal 8: 948958.
Butler DS, Moseley GL 2003 Explain Pain. Adelaide,
Noigroup Publications.
Clarke CL, Ryan CG, Martin DJ 2011 Pain neurophysiology
education for the management of individuals with chronic
low back pain: A systematic review and meta-analysis.
Manual Therapy 16: 544549.
de Morton NA 2009 The PEDro scale is a valid measure of
the methodological quality of clinical trials: A demo-
graphic study. Australian Journal of Physiotherapy 55:
129133.
Elkins MR, Herbert RD, Moseley AM, Sherrington C, Maher
CG 2010 Rating the quality of trials in systematic reviews
of physical therapy interventions. Cardiopulmonary
Physical Therapy Journal 21(3): 2026.
Engers A, Jellema P, Wensing M, van der Windt DA, Grol R,
van Tulder MW 2008 Individual patient education for low
back pain. Cochrane Database of Systematic Reviews (1):
CD004057.
Ezzo J, Berman B, Hadhazy VA, Jadad AR, Lao L, Singh BB
2000 Is acupuncture effective for the treatment of chronic
pain? A systematic review. Pain 86: 217225.
22 A. LOUW ET AL.
Downloaded by [Nova Southeastern University] at 06:31 30 June 2016
Farrar JT, Young JP, LaMoreaux L, Werth JL, Poole RM 2001
Clinical importance of changes in chronic pain intensity
measured on an 11-point numerical pain rating scale. Pain
94: 149158.
Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML,
Miangolarra JC, Barriga FJ, Pareja JA 2006 Are manual thera-
pies effective in reducing pain from tension-type headache?: A
systematic review. Clinical Journal of Pain 22: 278285.
Ferreira ML, Ferreira PH, Latimer J, Herbert R, Maher CG
2002 Does spinal manipulative therapy help people with
chronic low back pain? Australian Journal of
Physiotherapy 48: 277284.
Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG,
Komaroff A 1994 The chronic fatigue syndrome: A com-
prehensive approach to its definition and study.
International Chronic Fatigue Syndrome Study Group.
Annals of Internal Medicine 121: 953959.
Gallagher L, McAuley JH, Moseley GL 2013 A Randomized-
controlled trial of using a book of metaphors to
reconceptualize pain and decreass catastrophizing in peo-
ple with chronic pain. Clinical Journal of Pain 29: 2025.
Gifford L 1998 Pain, the tissues and the nervous system: A
coneptual model. Physiotherapy 84: 2736.
Gifford L 2014 Aches and Pain. Cornwall, UK, Aches and
Pain LTD.
Gifford L, Butler DS 1997 The integration of pain sciences
into clinical practice. Journal of Hand Therapy 10: 8695.
Gifford L, Muncey H 1999 Explaining Pain to Patients. Paper
presented at the International Association on the Study of
Pain, Vienna, Austria.
Haldeman S 1990 Presidential address, North American
Spine Society: Failure of the pathology model to predict
back pain. Spine 15: 718724.
Herbert RD 2000 How to estimate treatment effects from
reports of clinical trials. I: Continuous outcomes.
Australian Journal of Physiotherapy 46: 229235.
Heymans MW, van Tulder MW, Esmail R, Bombardier C,
Koes BW 2005 Back schools for nonspecific low back pain:
A systematic review within the framework of the Cochrane
Collaboration Back Review Group. Spine 30: 21532163.
Hirsch MS, Liebert RM 1998 The physical and psychological
experience of pain: The effects of labeling and cold pressor
temperature on three pain measures in college women.
Pain 77: 4148.
Ittersum MW, Wilgen CP, Schans CP, Lambrecht L,
Groothoff JW, Nijs J 2014 Written pain neuroscience
education in fibromyalgia: A multicenter randomized con-
trolled trial. Pain Practice 14: 689700.
Koes BW, van Tulder MW, van der Windt WM, Bouter LM
1994 The efficacy of back schools: A review of randomized
clinical trials. Journal of Clinical Epidemiology 47: 851862.
Liddle SD, Gracey JH, Baxter GD 2007 Advice for the
management of low back pain: A systematic review of
randomised controlled trials. Manual Therapy 12: 310327.
Louw A, Butler D 2011 Chronic pain. In Brotzman SB,
Manske RC (Eds), Clinical Orthopaedic Rehabilitation:
An Evidence-Based Approach. Philadelphia, PA, Elsevier
Health Sciences.
Louw A, Diener I, Butler DS, Puentedura EJ 2011 The effect
of neuroscience education on pain, disability, anxiety, and
stress in chronic musculoskeletal pain. Archives of Physical
Medicine and Rehabilitation 92: 20412056.
Louw A, Diener I, Butler DS, Puentedura EJ 2013
Preoperative education addressing postoperative pain in
total joint arthroplasty: Review of content and educational
delivery methods. Physiotherapy Theory and Practice 29:
175194.
Louw A, Diener I, Landers MR, Puentedura EJ 2014
Preoperative pain neuroscience education for lumbar radi-
culopathy: A multicenter randomized controlled trial with
1-year follow-up. Spine 39: 14491457.
Louw A, Louw Q, Crous LC 2009 Preoperative education for
lumbar surgery for radiculopathy. South African Journal of
Physiotherapy 65(2): 38.
Louw A, Puentedura EJ, Diener I, Peoples RR 2015
Preoperative therapeutic neuroscience education for lum-
bar radiculopathy: A single-case fMRI report.
Physiotherapy Theory and Practice 31: 496508.
Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins
M R 2003 Reliability of the PEDro scale for rating
quality of randomized controlled trials. Physical Therapy
83: 713721.
Maier-Riehle B, Härter M 2001 The effects of back schoolsa
meta-analysis. International Journal of Rehabilitation
Research 24: 199206.
Meeus M, Nijs J, Van Oosterwijck J, Van Alsenoy V, Truijen
S 2010 Pain physiology education improves pain beliefs in
patients with chronic fatigue syndrome compared with
pacing and self-management education: A double-blind
randomized controlled trial. Archives of Physical
Medicine and Rehabilitation 91: 11531159.
Mortimer M, Ahlberg G; MUSIC-Norrtälje Study Group
2003 To seek or not to seek? Care-seeking behaviour
among people with low-back pain. Scandinavian Journal
of Public Health 31: 194203.
Moseley GL 2002 Combined physiotherapy and education is
efficacious for chronic low back pain. Australian Journal of
Physiotherapy 48: 297302.
Moseley GL 2003a A pain neuromatrix approach to patients
with chronic pain. Manual Therapy 8: 130140.
Moseley GL 2003b Unraveling the barriers to reconceptuali-
zation of the problem in chronic pain: The actual and
perceived ability of patients and health professionals
to understand the neurophysiology. Journal of Pain 4:
184189.
Moseley GL 2003c Joining forces - Combining cognition -
Targeted motor control training with group or individual
painphysiology education: A successful tretment for
chronic low back pain. Journal of Manual and
Manipulative Therapy 11: 8894.
Moseley GL 2004 Evidence for a direct relationship between
cognitive and physical change during an education inter-
vention in people with chronic low back pain. European
Journal of Pain 8: 3945.
Moseley GL 2007 Reconceptualising pain according to
modern pain science. Physical Therapy Reviews 12:
169178.
Moseley GL, Butler D S 2015 Fifteen years of explaining
pain:Thepast,present,andfuture.JournalofPain16:
807813.
Moseley GL, Nicholas MK, Hodges PW 2004 A randomized
controlled trial of intensive neurophysiology education
in chronic low back pain. Clinical Journal of Pain 20:
324330.
PHYSIOTHERAPY THEORY AND PRACTICE 23
Downloaded by [Nova Southeastern University] at 06:31 30 June 2016
Nachemson AL 1992 Newest knowledge of low back pain a
critical look. Clinical Orthopaedics and Related Research
279: 820.
National Health and Medical Research Council 1999 How to
Review the Evidence: Systematic Identification and Review
of the Scientific Literature, Canberra, Australia.
Nijs J, Paul van Wilgen C, Van Oosterwijck J, van Ittersum
M, Meeus M 2011 How to explain central sensitization to
patients with unexplainedchronic musculoskeletal pain:
Practice guidelines. Manual Therapy 16: 413418.
Nijs J, Roussel N, Paul van Wilgen C, Koke A, Smeets R 2013
Thinking beyond muscles and joints: Therapistsand
patientsattitudes and beliefs regarding chronic musculos-
keletal pain are key to applying effective treatment. Manual
Therapy 18: 96102.
Pires D, Cruz EB, Caeiro C 2015 Aquatic exercise and pain
neurophysiology education versus aquatic exercise alone
for patients with chronic low back pain: A randomized
controlled trial. Clinical Rehabilitation 29: 538547.
Poiraudeau S, Rannou F, Baron G, Le Henanff A, Coudeyre E,
Rozenberg S, Huas D, Martineau C, Jolivet-Landreau I,
Garcia-Mace J 2006 Fear-avoidance beliefs about back pain
in patients with subacute low back pain. Pain 124: 305311.
Robinson V, King R 2011 Explaining Painas part of a pain
management service improves patients understanding of
the neurophysiology of chronic pain. Journal of the
Physiotherapy Pain Association 32: 2730.
Rönnberg K, Lind B, Zoëga B, Halldin K, Gellerstedt M,
Brisby H 2007 Patientssatisfaction with provided care/
information and expectations on clinical outcome after
lumbar disc herniation surgery. Spine 32: 256261.
Ryan CG, Gray HG, Newton M, Granat MH 2010 Pain
biology education and exercise classes compared to pain
biology education alone for individuals with chronic low
back pain: A pilot randomised controlled trial. Manual
Therapy 15: 382387.
Stone PW 2002 Popping the (PICO) question in research and
evidence-based practice. Applied Nursing Research 15:
197198.
Téllez-García M, de-la-Llave-Rincón AI, Salom-Moreno J,
Palacios-Ceña M, Ortega-Santiago R, Fernández-de-las-
Peñas C 2014 Neuroscience education in addition to trig-
ger point dry needling for the management of patients
with mechanical chronic low back pain: A preliminary
clinical trial. Journal of Bodywork and Movement
Therapy 19: 464472.
VanIttersumMW,vanWilgenCP,GroothoffJW,Van
derSchansCP2011Isappreciationofwritteneduca-
tion about pain neurophysiology related to changes in
illness perceptions and health status in patients with
fibromyalgia? Patient Education and Counseling 85:
269274.
Van Oosterwijck J, Meeus M, Paul L, De Schryver M, Pascal
A, Lambrecht L, Nijs J 2013 Pain physiology education
improves health status and endogenous pain inhibition in
fibromyalgia: A double-blind randomized controlled trial.
Clinical Journal of Pain 29: 873882.
Van Oosterwijck J, Nijs J, Meeus M, Truijen S, Craps J, Van
den Keybus N, Paul L 2011 Pain neurophysiology educa-
tion improves cognitions, pain thresholds, and movement
performance in people with chronic whiplash: A pilot
study. Journal of Rehabilitation Research and
Development 48: 4358.
Vibe Fersum K, OSullivan P, Skouen J S, Smith A, Kvåle A
2013 Efficacy of classification-based cognitive functional
therapy in patients with non-specific chronic low back
pain: A randomized controlled trial. European Journal of
Pain 17: 916928.
Waddell G 2004 The Back Pain Revolution. Philadelphia, PA,
Elsevier Health Sciences.
Woolf CJ 2007 Central sensitizationuncovering the relation
between pain and plasticity. Journal of the American
Society of Anesthesiologists 106: 864867.
Zimney K, Louw A, Puentedura EJ 2014 Use of
Therapeutic Neuroscience Education to address psy-
chosocial factors associated with acute low back pain:
A case report. Physiotherapy Theory and Practice 30:
202209.
24 A. LOUW ET AL.
Downloaded by [Nova Southeastern University] at 06:31 30 June 2016
... 55 Additionally, pain neuroscience education for chronic musculoskeletal conditions reduces psychosocial factors and improved movement impairments. 56 While there is limited research directly comparing interventions across AKP and ACLR groups, the lack of differ-The Comparison of Psychological Barriers Between Individuals with a History of Anterior Knee Pain, Anterior Cruciate... ence in psychological variables from our data suggests multiple interventions may be beneficial to patients with knee related injuries. ...
Article
Background Psychological barriers due to anterior knee pain (AKP) and anterior cruciate ligament reconstruction (ACLR) may have a direct impact on an individual’s return to physical activity. A comprehensive understanding of these psychological barriers in individuals with AKP and ACLR may help clinicians to develop and implement better treatment strategies to address deficits that may exist in these individuals. Hypothesis/Purpose The primary purpose of this study was to evaluate fear-avoidance, kinesiophobia, and pain catastrophizing in individuals with AKP and ACLR compared with healthy individuals. The secondary purpose was to directly compare psychological characteristics between the AKP and ACLR groups. It was hypothesized that 1) individuals with AKP and ACLR would self-report worse psychosocial function than healthy individuals and 2) the extent of the psychosocial impairments between the two knee pathologies would be similar. Study Design Cross-sectional study. Methods Eighty-three participants (28 AKP, 26 ACLR, and 29 healthy individuals) were analyzed in this study. Fear avoidance belief questionnaire (FABQ) with the physical activity (FABQ-PA) and sport (FABQ-S) subscales, Tampa scale of Kinesiophobia (TSK-11) and pain catastrophizing scale (PCS) assessed psychological characteristics. Kruskal-Wallis tests were used to compare the FABQ-PA, FABQ-S, TSK-11, and PCS scores across the three groups. Mann-Whitney U tests were performed to determine where group differences occurred. Effect sizes (ES) were calculated with the Mann-Whitney U z-score divided by the square root of the sample size. Results Individuals with AKP or ACLR had significantly worse psychological barriers compared to the healthy individuals for all questionnaires (FABQ-PA, FABQ-S, TSK-11, and PCS) (p<0.001, ES>0.86). There were no differences between the AKP and ACLR groups (p≥0.67), with a medium ES (-0.33) in the FABQ-S between AKP and ACLR groups. Conclusion Greater psychological scores indicate impaired psychological readiness to perform physical activity. Clinicians should be aware of fear-related beliefs following knee-related injuries and are encouraged to measure psychological factors during the rehabilitation process. Level of Evidence 2
... The mechanism of action of PNE is unclear, but there is strong evidence on PNE improving pain, catastrophization, fear of pain, as well as increasing patient's knowledge on the mechanism of pain in musculoskeletal conditions. [7,8] PNE is most commonly used in musculoskeletal conditions as its implementation is easier in these patients. Its efficacy in cancer rehabilitation, sports rehabilitation, and pediatric rehabilitation is being researched. ...
... The presence of YF simply indicates that there are psychosocial factors that should be addressed for optimal outcome (25,26). For example, YF may result in higher levels of nociplastic pain (28), as well as psychosocial issues that may interfere with conservative care. Yellow flags should be addressed whether they are directly due to UCI or other issues the patient may be dealing with. ...
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Experts in symptomatic generalized joint hypermobility (S-GJH) agree that upper cervical instability (UCI) needs to be better recognized in S-GJH, which commonly presents in the clinic as generalized hypermobility spectrum disorder and hypermobile Ehlers-Danlos syndrome. While mild UCI may be common, it can still be impactful; though considerably less common, severe UCI can potentially be debilitating. UCI includes both atlanto-occipital and atlantoaxial instability. In the absence of research or published literature describing validated tests or prediction rules, it is not clear what signs and symptoms are most important for diagnosis of UCI. Similarly, healthcare providers lack agreed-upon ways to screen and classify different types or severity of UCI and how to manage UCI in this population. Consequently, recognition and management of UCI in this population has likely been inconsistent and not based on the knowledge and skills of the most experienced clinicians. The current work represents efforts of an international team of physical/physiotherapy clinicians and a S-GJH expert rheumatologist to develop expert consensus recommendations for screening, assessing, and managing patients with UCI associated with S-GJH. Hopefully these recommendations can improve overall recognition and care for this population by combining expertise from physical/physiotherapy clinicians and researchers spanning three continents. These recommendations may also stimulate more research into recognition and conservative care for this complex condition.
... In non-cancer populations, international guidelines emphasize education, active and psychological therapies, and self-management skills, as frontline interventions for persistent pain [8][9][10][11]. Pain science education is a core component of these non-pharmacological interventions [12]. Pain science education aims to promote a contemporary understanding of "how pain works." ...
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Full-text available
Purpose Here, we describe the development and pilot study of a personalized eHealth intervention containing a pain science education program and self-management support strategies regarding pain and pain-related functioning in female survivors of breast cancer. First, we aimed to evaluate the eHealth intervention’s acceptability, comprehensibility, and satisfaction; second, we aimed to assess its preliminary efficacy. Methods A mixed-method study design was used. Breast cancer survivors with persistent pain were recruited. After 6 weeks of engagement with the eHealth intervention, acceptability, comprehensibility, and satisfaction were measured quantitatively with a self-constructed questionnaire and described qualitatively using focus groups. A joint display was used to present the meta-interferences between data. Efficacy was assessed via mixed effects models with repeated measures (outcomes assessed at baseline, 6 weeks, and 12 weeks). Results Twenty-nine women with persistent pain after breast cancer surgery participated. Overall, the eHealth program was well received and experienced as easy to use and helpful. The eHealth intervention seems useful as an adjunct to comprehensive cancer aftercare. Efficacy estimates suggested a significant improvement in pain-related functioning, physical functioning, and quality of life. Conclusion A personalized eHealth intervention appears valuable for persistent pain management after breast cancer surgery. A large controlled clinical trial to determine effectiveness, and a full process evaluation, seems warranted.
... Studies have shown that pain neuroscience education (PNE) generates significant effects on variables such as kinesiophobia, pain perception, pain intensity, disability and catastrophism [12]. However, the authors of previous systematic reviews [13][14][15][16][17] did not focus on psychoemotional variables such as hypervigilance, anxiety, and attitudes and beliefs towards pain nor cognitive variables such as the patient's knowledge regarding chronic pain. For this reason, we evaluated the effects of PNE on psychoemotional and cognitive variables in individuals with chronic musculoskeletal pain. ...
Article
Background Chronic pain is a global problem, with a prevalence of 35–50%. This multifactorial condition is influenced by biological, psychological, and social factors. Objectives We assessed the efficacy of pain neuroscience education (PNE) on psychoemotional and cognitive variables in individuals with chronic musculoskeletal pain. Methods We searched the PubMed, PEDro, Scopus, Web of Science, and CINHAL databases. We included randomised controlled trials conducted in adults with chronic musculoskeletal pain undergoing with PNE. The authors of these papers evaluated hypervigilance, attitudes and beliefs, knowledge of pain, and/or anxiety. We assessed risk of bias by using the ROB 2.0 tool. We performed a GRADE analysis to determine the quality of the evidence. We have reported the results using descriptive statistics and narrative synthesis. Results We included 10 articles that had implemented PNE. There were moderate to high effect sizes for the variables anxiety and knowledge of neurophysiology of pain and a moderate effect size for hypervigilance. Heterogeneity in the diagnosis of the participants, interventions, and follow-up periods did not allow us to perform a meta-analysis. Conclusions The results suggest that there are benefits of PNE alone or in combination with another therapeutic modality. However, more research is required.
Article
Aim To assess the efficacy of pain neuroscience education combined with physiotherapy for the management of migraine. Background Physiotherapy can significantly reduce the frequency of migraine, but the evidence is based only on a few studies. Pain neuroscience education might pose a promising treatment, as it addresses migraine as a chronic pain disease. Methods In this non-blinded randomized controlled trial, migraine patients received physiotherapy + pain neuroscience education or physiotherapy alone, preceded by a three-month waiting period. Primary outcomes were frequency of headache (with and without migraine features), frequency of migraine and associated disability. Results Eighty-two participants were randomized and analyzed. Both groups showed a decrease of headache frequency (p = 0.02, d = 0.46) at post-treatment (physiotherapy: 0.77 days, 95%CI: −0.75 to 2.29 and physiotherapy + pain neuroscience education: 1.25 days, 95%CI: −0.05 to 2.55) and at follow-up (physiotherapy: 1.93, 95%CI: 0.07 to 3.78 and physiotherapy + pain neuroscience education: 3.48 days, 95%CI: 1.89 to 5.06), with no difference between groups (p = 0.26, d = 0.26). Migraine frequency was reduced significantly in the physiotherapy + pain neuroscience education group, and not in the physiotherapy group, at post-treatment (1.28 days, 95%CI: 0.34 to 2.22, p = 0.004) and follow-up (3.05 days, 95%CI: 1.98 to 5.06, p < 0.0001), with a difference between groups at follow-up (2.06 days, p = 0.003). Migraine-related disability decreased significantly in both groups (physiotherapy: 19.8, physiotherapy + pain neuroscience education: 24.0 points, p < 0.001, d = 1.15) at follow-up, with no difference between groups (p = 0.583). Secondary outcomes demonstrated a significant effect of time with no interaction between time and group. No harm or adverse events were observed during the study. Conclusion In comparison to physiotherapy alone, pain neuroscience education combined with physiotherapy can further reduce the frequency of migraine, but had no additional effect on general headache frequency or migraine-related disability. Trial Registration The study was pre-registered at the German Clinical Trials Register (DRKS00020804).
Article
Introduction This study aimed to test group Physiotherapy sessions – pain education and supervised exercise − in addition to individual consultations, for women referred with persistent pelvic pain (with/without endometriosis), with the primary outcomes being pain scores and pain impact. Methods Parallel study design with three treatment arms: (1) usual care: a suite of individual Physiotherapy consultations; (2) introductory group pain education session followed by usual care and (3) introductory group pain education session followed by usual care and an 8-week supervised group exercise programme. Results Ninety women were recruited (30/treatment arm), with 66 women (73%) completing their allocated treatment. Participants were aged between 16 and 51 years; endometriosis was confirmed in 41% ( n = 27/66) of the study population. Data was analysed using descriptive and inferential statistics. Statistically significant gains ( p < 0.05) in pain scores and pelvic pain impact scores were observed in all arms. Between groups, there was statistically significant improvement ( p < 0.05) in pelvic pain impact score for those who attended the group pain education session followed by usual care (arm 2), compared to usual care (arm 1) alone. There was no significant added improvement with the weekly supervised group exercise programme (arm 3), when compared to those who received the group pain education programme and usual care (arm 2). Conclusion This study has demonstrated positive benefits of a group pain education session on pain scores and pelvic pain impact for women referred with persistent pelvic pain, when added as a precursor to individual Physiotherapy consultations.
Article
Purpose The purpose of this paper was first to gain an in-depth understanding of the barriers and facilitators to implementing the BPS model and pain neuroscience education in the current Lebanese physical therapy health care approach and explore its acceptability. Method A qualitative semi-structured interview using purposive sampling was conducted with eight Lebanese physical therapists practising in different governorates. The transcribed text from the interviews was analyzed using inductive thematic analysis. Results Two topics were generated and constructed by the researchers: (1) “barriers to the implementation of pain neuroscience education, with subthemes including (a) “current health care approach,” (b) “basic curriculum and continuing education,” (c) “patients’ barriers”; (2) “facilitators to the implementation of pain neuroscience education,” with subthemes containing (a) “interest in the BPS model, (b) “therapeutic alliance,” and (c) “motivation for future training on BPS approach.” Conclusion The analysis of the results showed that Lebanese physical therapists currently hold a strong biomedical view of chronic pain, assessment, and treatment. However, despite the presence of barriers and challenges, they are aware and open to consider the implementation and future training about the BPS model and pain neuroscience education in their approach. • IMPLICATIONS FOR REHABILITATION • The exploration of potential barriers and facilitators to the bio-psychosocial model and pain neuroscience education implementation may provide an opportunity for better development and design of a culturally sensitive pain neuroscience education material for Arab-speaking and Lebanese physical therapists. • The exploration of barriers and facilitators to the implementation of pain neuroscience education will help to improve pain education and ensure better clinical pain management. • The most important barriers were the dominant characteristic of the Lebanese physical therapist’s health approach, which is focused on a biomechanically oriented model, and their lack of knowledge to approach chronic pain from a biopsychosocial perspective.
Article
Objectives: Chronic pain is highly prevalent and a leading cause of disability. Long wait times for interprofessional care provide an opportunity to introduce web-based interventions that improve psychosocial function and patients' readiness and ability to manage their condition. Here we describe the process of partnering with people with lived experience (PWLE) to develop an online self-management program enhanced by motivational interviewing. We also report the multiphase usability testing of the program. Methods: PWLE were included in all aspects of this project from program inception to content creation, module development, usability testing, and knowledge dissemination. Phase 1 included the development of the interactive, web-based modules. This process involved weekly meetings and asynchronous content creation with a core team of interprofessional pain experts, researchers, and PWLE. Phase 2 included usability testing by our PWLE and clinical expert advisory. Phase 3 included survey-based usability testing with a sample of 10 PWLE. Results: We created a chronic pain & motivational empowerment program includes a series of eight interactive educational web-based modules. Topics included: setting expectations, chronic pain explained, biopsychosocial factors, empowered management, self-awareness & compassion & acceptance, values, goal setting, and communication. The program is accompanied by a reflection journal and can be enhanced by one-on-one coaching sessions using a motivational interviewing approach. Phase two usability testing resulted in numerous content changes and the addition of accessibility features. Phase 3 usability testing with PWLE found the program highly accessible and easy to use. Conclusions: The engagement of our PWLE team member and advisors made the online program more relevant, sensitive and helpful to the needs of people with pain. Practical value: This PWLE-centric project sets the foundation for future work to examine the feasibility and effectiveness of the program for supporting individuals with chronic pain self-manage.
Article
Pain is one of the most prevalent and long‐term adverse effects described by people who have undergone breast cancer surgery. Non‐helpful perceptions and thoughts about pain may contribute to the transition of acute to persistent pain. Adding educational interventions to the current physical therapy program in this population may help to improve or prevent persistent pain. Pain neuroscience education (PNE) is a type of educational intervention that addresses the experience of pain in a broader sense by explaining pain not only from a biomedical perspective, but also from a psychological and social perspective. A double‐blinded randomized controlled trial (EduCan trial) investigated whether PNE, in addition to a standard physiotherapy program immediately after surgery for breast cancer, was more effective on somatosensory functioning in the short (4 months postoperatively) and long term (18 months postoperatively), than providing a biomedical explanation for pain. Somatosensory functioning was evaluated using a self‐reported questionnaire as well as a comprehensive quantitative sensory testing evaluation. The findings of this study revealed that adding six sessions of PNE to a standard physical therapy program (n = 184) did not result in a significantly different course of somatosensory functioning up to 18 months postoperatively as compared to biomedical pain education. These findings provide an interesting basis for future research into who should receive PNE after surgery for breast cancer (e.g., patient profiling or phenotyping) and how we can tailor it to the individual to increase its effectiveness.
Article
Full-text available
To date no studies have been published on preoperative education forpatients who had lumbar surgery. The aim of this study was to determine if there is a demand for preoperative education for patients who had lumbar surgery for radiculopathy. A convenience sample of 47 patients who had lumbar surgery and a random sample of 141 physiotherapists involved in treating patients who had lumbar surgery completed a newly developed spinal surgery questionnaire. The data were analyzed using descriptiveand inferential statistical tests. Results showed that 100% of the patients and 99% of therapists view preoperative education to be an important component for lumbar surgery for radiculopathy. The most important factors identifiedfor inclusion in preoperative educational programs were reason for surgery, risks associated with surgery, limitations following surgery and more education regarding pain. The preferred method of education delivery was verbal one-on-one education. This study demonstrates that there is a demand for preoperative education for patients who had lumbar surgery.
Article
Full-text available
To date no studies have been published on preoperative education for patients who had lumbar surgery. The aim of this study was to determine if there is a demand for preoperative education for patients who had lumbar surgery for radiculopathy. A convenience sample of 47 patients who had lumbar surgery and a random sample of 141 physiotherapists involved in treating patients who had lumbar surgery completed a newly developed spinal surgery questionnaire. The data were analyzed using descriptive and inferential statistical tests. Results showed that 100% of the patients and 99% of therapists view preoperative education to be an important component for lumbar surgery for radiculopathy. The most important factors identified for inclusion in preoperative educational programs were reason for surgery, risks associated with surgery, limitations following surgery and more education regarding pain. The preferred method of education delivery was verbal one-on-one education. This study demonstrates that there is a demand for preoperative education for patients who had lumbar surgery.
Article
Background and purpose: Assessment of the quality of randomized controlled trials (RCTs) is common practice in systematic reviews. However, the reliability of data obtained with most quality assessment scales has not been established. This report describes 2 studies designed to investigate the reliability of data obtained with the Physiotherapy Evidence Database (PEDro) scale developed to rate the quality of RCTs evaluating physical therapist interventions. Method: In the first study, 11 raters independently rated 25 RCTs randomly selected from the PEDro database. In the second study, 2 raters rated 120 RCTs randomly selected from the PEDro database, and disagreements were resolved by a third rater; this generated a set of individual rater and consensus ratings. The process was repeated by independent raters to create a second set of individual and consensus ratings. Reliability of ratings of PEDro scale items was calculated using multirater kappas, and reliability of the total (summed) score was calculated using intraclass correlation coefficients (ICC [1,1]). Results: The kappa value for each of the 11 items ranged from.36 to.80 for individual assessors and from.50 to.79 for consensus ratings generated by groups of 2 or 3 raters. The ICC for the total score was.56 (95% confidence interval=.47-.65) for ratings by individuals, and the ICC for consensus ratings was.68 (95% confidence interval=.57-.76). Discussion and conclusion: The reliability of ratings of PEDro scale items varied from "fair" to "substantial," and the reliability of the total PEDro score was "fair" to "good."
Article
Pain is the major complaint of the estimated one million U.S. consumers who use acupuncture each year. Although acupuncture is widely available in chronic pain clinics, the effectiveness of acupuncture for chronic pain remains in question. Our aim was to assess the effectiveness of acupuncture as a treatment for chronic pain within the context of the methodological quality of the studies. MEDLINE (1966-99), two complementary medicine databases, 69 conference proceedings, and the bibliographies of other articles and reviews were searched. Trials were included if they were randomized, had populations with pain longer than three months, used needles rather than surface electrodes, and were in English. Data were extracted by two independent reviewers using a validated instrument. Interrater disagreements were resolved by discussion. Fifty one studies met inclusion criteria. Clinical heterogeneity precluded statistical pooling. Results were positive in 21 studies, negative in 3 and neutral in 27. Three fourths of the studies received a low-quality score and low-quality trials were significantly associated with positive results (p = 0.05). High-quality studies clustered in designs using sham acupuncture as the control group, where the risk of false negative (type II) errors is high due to large sample size requirements. Six or more acupuncture treatments were significantly associated with positive outcomes (p = 0.03) even after adjusting for study quality. We conclude there is limited evidence that acupuncture is more effective than no treatment for chronic pain; and inconclusive evidence that acupuncture is more effective than placebo, sham acupuncture or standard care. However, we have found an important relationship between the methodology of the studies and their results that should guide future research.