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Influence of education level on the effectiveness of pain neuroscience education: A secondary analysis of a randomized controlled trial
Abstract
Background
Current evidence supports the use of pain neuroscience education (PNE) in several chronic pain populations. However, the effects of PNE at group level are rather small and little is known about the influence of personal factors (e.g. level of education [LoE]).
Objective
To examine whether the effectiveness of PNE differs in chronic spinal pain (CSP) patients with high LOE (at least a Bachelor's degree) versus lower educated patients.
Method
A total of 120 Belgian CSP patients were randomly assigned to the experimental (PNE) or control group (biomedical-focused neck/back school). Participants within each group were further subcategorized based on highest achieved LoE. ANOVA and Bonferroni post-hoc analyses were used to evaluate differences in effectiveness of the interventions between higher and lower educated participants.
Results
No differences between higher and lower educated participants were identified for pain-related disability. Significant interactions (P < 0.05) were found for kinesiophobia and several illness perceptions components. Bonferroni post-hoc analysis revealed a significant improvement in kinesiophobia (P < .001 and P < .002, medium effect sizes) and perceived negative consequences (P < .001 and P < .008, small effect sizes) in the PNE groups. Only the higher education PNE group showed a significant improvement in perceived illness cyclicity (P = .003, small effect size). Post-treatment kinesiophobia was significant lower in the higher educated PNE group compared to the higher educated control group (p < 0.001).
Conclusion
Overall, the exploratory findings suggest no clinical meaningful differences in effectiveness of PNE between higher and lower educated people. PNE is effective in improving kinesiophobia and several aspects of illness perceptions regardless of LoE.
... Patients will complete the Neurophysiology of Pain Test before and after PNE sessions [47], with their level of understanding determined by their scores. Research has shown that patients with a higher level of education are more likely to improve their pain biology knowledge after PNE sessions [51,52]. Therefore, we will consider the influence of this variable. ...
... Therefore, we will consider the influence of this variable. Based on the study of Thomas Bilterys et al. [52], participants will be grouped by their level of education and treatment arm to compare the treatment's effectiveness in individuals with higher versus lower education. Educational attainment will be used to divide the participants in both the experimental and control group into subgroups based on their self-reported level of education: "What is the highest education degree you have received?". ...
... Educational attainment will be used to divide the participants in both the experimental and control group into subgroups based on their self-reported level of education: "What is the highest education degree you have received?". Participants with at least a Bachelor's degree will be allocated to the higher education group, while others will be allocated to the lower education group [52]. ...
Objective
Chronic low back pain (CLBP) is a prevalent health condition worldwide. Several therapeutic interventions aim to improve CLBP. Pain Neuroscience Education (PNE) helps patients better understand their pain from biological and physiological perspectives, which clinicians use to reduce pain and disability in patients with chronic musculoskeletal conditions. Neuromuscular exercises (NMS) are also treatments adopted in CLBP. This study will investigate whether PNE combined with an NMS program improves pain, functional and psychological outcomes more than NMS alone in patients with CLBP.
Methods
In this single-blind randomized controlled trial, 60 patients (male and female; age range, 30–60 years) diagnosed with CLBP will be randomly assigned to one of the following groups: (1) PNE plus NMS (n = 30; 24 sessions of PNE plus NMS in a total of 8 weeks, 3 each week), and (2) NMS alone (n = 30; 24 sessions of NMS sessions in a total of 8 weeks, 3 each week). Outcome assessors will be blinded to the group allocation. The primary outcome will be pain. Secondary outcomes will be disability, fear-avoidance beliefs about work and physical activity, self-efficacy, exercise anxiety, and kinesiophobia. Outcomes will be assessed at baseline, after 8 weeks of intervention, and 6 months post-intervention.
Discussion
The findings of this RCT will help shed light on new treatment strategies to address the biopsychosocial dimensions of CLBP. The study protocol will be conducted in a clinical setting, offering the opportunity for future implementation in healthcare systems. Moreover, it will help clarify whether a combined treatment (PNE with NMS) is more effective than NMS alone for improving pain, functional and psychological outcomes in CLBP.
Trial registration
Study registration: The study was prospectively registered in the Iranian Registry of Clinical Trials—IRCT20190427043384N2 (https://www.irct.ir/trial/69146). Registered on March 17, 2023.
... Some studies have indicated that care seekers for vulvodynia were more likely to have a college education [32,33], with approximately 60% having a college or graduate degree [28]. However, no significant differences in pain-related disability were identified between higher and lower-educated participants [34,35]. ...
... Some studies have reported that a majority of patients with vulvar dermatosis were illiterate [31], while others have found that care seekers with chronic vulvar pain were more likely to have a university education [32]. Conversely, certain studies have failed to identify any significant differences in educational levels concerning vulvar pain [34][35]. ...
This study aims to provide a descriptive analysis of the essential characteristics and demographic profiles, including age, weight, height, body mass index, marital status, and educational background in patients with chronic vulvar discomfort. The data were collected from the study DATRIV (Diagnostic Accuracy of Three Rings Vulvoscopy), which included 328 participants divided into four groups: normal vulva, impaired vulvar skin, primary vulvar distress/vulvodynia, and secondary discomfort caused by vulvar dermatoses. The clinical data collected from the study questionnaire were analyzed using statistical software such as StatSoft (Dell, Austin, TX, USA), Statistica 12 (TIBCO®, Palo Alto, CA, USA), and SPSS 20 (IBM, Armonk, NY, USA). The study was conducted with the approval of the Institutional Review Board of Polyclinic Harni, and all participants provided written informed consent. The findings from the DATRIV study shed light on several important aspects of chronic vulvar discomfort. They offered valuable insights into the demographic and reproductive characteristics of patients with chronic vulvar pain, specifically vulvar dermatosis. The study revealed that patients with vulvar dermatosis tended to be older, with a peak incidence in the 45-65 age range. They also had higher weight and BMI compared to other groups. There was a significant difference in the proportion of patients of reproductive age between the vulvar dermatosis group and other groups. Additionally, the vulvar dermatosis group had higher rates of marriage, births, and abortions and lower educational levels. The study's limitations included lacking patients younger than 16 years. Future research should aim to include a broader age range, including pediatric populations, to gain a more comprehensive understanding of vulvar dermatosis across different age groups. Further investigation is needed to uncover the underlying mechanisms and establish causal relationships, enhancing diagnosis, treatment, and support for individuals affected by vulvar dermatosis.
... Participants with higher educational attainment and females were more likely to report better well-being and self-efficacy after 6 weeks of intervention. This finding is unsurprising, as higher education may afford individuals greater insight into and comprehension of pain education programs, aiding in pain management and mitigating challenges associated with LBP [46,47]. However, overall, significant improvements were observed in the primary outcomes (RMDQ and VAS) and well-being in the pain intervention group compared to the control group. ...
... Notably, an improvement of 30% or more in RMDQ score is rated as clinically relevant [51]. These findings further strengthen the claim on the effectiveness of the pain education intervention in reducing disability related to CLBP, which is consistent with studies reporting the efficacy of pain education interventions [13,30,47,49]. Regarding pain intensity, as measured by the Visual Analog Scale (VAS), both the experimental and control groups showed a significant decrease following the intervention. ...
Background
Low back pain stands as a prevalent contributor to pain-related disability on a global scale. In addressing chronic low back pain (CLBP), there is a growing emphasis on incorporating psychological strategies into the management process. Among these, pain education interventions strive to reshape pain beliefs and mitigate the perceived threat of pain. This randomized controlled trial sought to assess the effects of pain education on various aspects, including pain levels, disability, quality of life, self-efficacy, and prognostic characteristics in individuals grappling with CLBP.
Methods
The clinical trial, retrospectively registered with the Clinical Trials Registry of India (CTRI/2021/08/035963), employed a two-arm parallel randomized design. Ninety-two participants with CLBP were randomly assigned to either the standard physiotherapy care with a pain education program or the control group. Both groups underwent a 6-week intervention. Assessment of pain intensity (using NPRS), disability (using RMDQ), self-efficacy (using the general self-efficacy scale), and well-being (using WHO 5I) occurred both before and after the 6-week study intervention.
Findings
Post-intervention score comparisons between the groups revealed that the pain education intervention led to a significant reduction in disability compared to the usual standard care at 6 weeks (mean difference 8.2, p < 0.001, effect size Cohen d = 0.75), a decrease in pain intensity (mean difference 3.5, p < 0.001, effect size Cohen d = 0.82), and an improvement in the well-being index (mean difference 13.7, p < 0.001, effect size Cohen d = 0.58).
Conclusion
The findings suggest that integrating a pain education program enhances the therapeutic benefits of standard physiotherapy care for individuals dealing with chronic LBP. In conclusion, the clinical benefits of pain education become apparent when delivered in conjunction with standard care physiotherapy during the management of chronic low back pain.
... Education can reduce kinesiophobia [15,34,35], by changing/decreasing fear beliefs. This may facilitate patients' understanding of the value of gradually exposing themselves to the activities they fear [35]. ...
... The patients will then understand that pain is not equal to harm, persisting pain is not correlated with tissue damage, and that pain is modulated by many factors [36]. Pain neuroscience education (PNE) has evolved in recent years and has demonstrated a reduction in pain-related fear [34,37]. Finally, to maximize the effect of education on the reduction of kinesiophobia, it seems appropriate to combine it with physical therapy [38]. ...
Kinesiophobia is described as pain-related fear of movement and plays a role in the development of chronic musculoskeletal pain. Several approaches have been described in the literature, but there does not seem to be a consensus on the most appropriate way to evaluate and treat patients with kinesiophobia. The aim of this study was to identify clinically relevant assessments and treatments recommended by a consensus of experts. Fourteen experts were identified to participate in a three-round internet-based Delphi study. Participants were asked to propose assessments and treatments (round 1), to grade each proposal on a Likert scale of 9 (round 2), and to reassess their level of agreement (round 3). The consensus was defined with 75% agreement. Five methods of assessment and six treatment approaches reached a consensus. The TAMPA scale reached the top position as an assessment of kinesiophobia. Graded exposure to movement, cognitive and behavioral therapy, and pain neuroscience education were the highest-rated interventions. These results provide the first expert consensus on preferred assessments and treatments for patients with kinesiophobia and correspond with the evidence base in the literature.
... Addressing fearavoidance behaviors through patient education focusing gradually on building their confidence in movement and exercise could enhance patient compliance with physical therapy interventions. 14 In fact, a recent randomized controlled trial has reported that pain neuroscience education effectively reduced kinesiophobia and improved various aspects of illness perceptions across different educational levels, indicating its broad applicability and potential benefits for individuals with lower levels of education, 28 as observed in our study. ...
Introduction: Shoulder pain (SP) is a common concern impacting the quality of life (QOL) and productivity among Nepalese farmers. However, the factors contributing to SP are not fully understood. This study aimed to identify the bio-psychosocial factors influencing SP and disability in Nepalese farmers. Methods: 122 full-time farmers seeking treatment for SP participated in this cross-sectional study. The Nepalese version of the Shoulder Pain and Disability Questionnaire (SPADI-NP), the 11-item Tampa Scale of Kinesiophobia (TSK-11-NP), and the Pain Catastrophizing Scale (PCS-NP) were used for data collection. Univariate and multivariate linear regressions were used to determine the contributing factors of SP and disability. Results: TSK-11-NP, PCS-NP, age, gender, and education were significantly associated with the SPADI-NP, with TSK-11-NP (R2=0.42) and PCS-NP (R2=0.40) demonstrating the highest association. The first model with a constant and TSK-11-NP explained 42% of the variance in SPADI-NP. Adding age, gender, and education sequentially, the model improved the ability to explain the variance in SPADI-NP to 46%, 48%, and 50%, respectively. The results indicated that psychological factors were the strongest factor associated with SP and disability in Nepalese farmers. Conclusions: Heightened kinesiophobia, pain catastrophization, advancing age, female gender, and low level of education significantly contributed to SP and disability in Nepalese farmers. A comprehensive approach addressing these bio-psychosocial factors would be necessary for managing SP and disability and possibly improving the QOL of the local farmers in the region.
... Of 787 non-duplicated citations identified in the literature, 19 were further analysed to confirm their eligibility. Twelve were excluded after full-text reading: four as they included participants with concurrent low back pain (Bilterys et al., 2022;Malfliet, Kregel, Coppieters, et al., 2018;Van Bogaert et al., 2021), two for not being RCTs (Jessica Van Oosterwijck et al., 2011;Louw et al., 2022), one for not reporting pain intensity and kinesiophobia (Willaert et al., 2020), two for lacking control groups and not using PNE (Brage et al., 2015;Ris et al., 2016), two for using the bio-behavioural approach instead of PNE (Beltran-Alacreu et al., 2015;López-de-Uralde-Villanueva et al., 2018), and one for having participants overlapping with another publication by the author . The reasons for exclusion are listed in Table S3. ...
Background:
Chronic neck pain (CNP) is a common musculoskeletal disorder. Pain neuroscience education (PNE) is a promising nonpharmacological intervention for CNP, however, its effectiveness remains unclear. This systematic review and meta-analysis aimed to evaluate the effectiveness of PNE in treating CNP.
Methods:
Electronic databases from inception to February 2023 were searched for randomized controlled trials (RCTs) on the effects of PNE on CNP. The primary outcome was the change in pain intensity, and the secondary outcome was improvement in kinesiophobia, standardized using Hedges' g. Two authors independently scrutinized eligible articles, extracted data and assessed quality; a random-effects model was employed for data pooling.
Results:
In total, seven RCTs comprising 479 participants were included and demonstrated that PNE significantly reduced pain intensity (Hedges' g = -0.730, 95% CI = -1.340 to -0.119, p = 0.019, I2 = 89.288%). Subgroup analysis revealed that the adult group experienced significant pain reduction after PNE, whereas the adolescent group did not. PNE also reduced kinesiophobia which was evaluated in four of seven RCTs (Hedges' g = -0.444, 95% CI = -0.735 to -0.154, p = 0.003, I2 = 36.822%). The meta-regression analysis indicated that an increased intervention duration contributed to greater pain reduction. No adverse events were reported following PNE or the control treatment.
Conclusions:
PNE effectively reduced pain intensity and kinesiophobia in patients with CNP. A longer PNE time leads to greater pain reduction and is more effective in adults than in adolescents. Further studies are required to examine the long-term effects on CNP management.
Significance:
This is the first meta-analysis evaluating the effectiveness of treating chronic neck pain with pain neuroscience education. Pain neuroscience education is successful in reducing pain and decreasing kinesiophobia in the chronic neck pain population. Longer treatment time leads to greater pain reduction.
... Researchers suggested that better financial and social conditions acquired by education can positively influence one's lifestyle and increase their quality of life [49,76,77]. A previous study reported no differences between higher and lower educated participants in terms of pain-related disability [78]. As mentioned earlier, individuals with higher educational levels are reported to have better functional level; thus, it is likely that they may have lower degrees of kinesiophobia. ...
IntroductionAlthough the negative effects of kinesiophobia on functional status in subacromial pain syndrome (SAPS) patients are clearly demonstrated, no study examines the risk factors of kinesiophobia in individuals with SAPS from a biopsychosocial perspective. The present study aims to determine the risk factors of kinesiophobia in individuals with SAPS using a biopsychosocial approach. This study also aims to explore the compounding effects of multiple associative risk factors by developing a clinical prediction tool to identify SAPS patients at higher risk for kinesiophobia.Materials and methodsThis cross-sectional study included 549 patients who were diagnosed with SAPS. The Tampa-Scale of Kinesiophobia (TSK) was used to assess kinesiophobia. Visual analog scale (VAS), The Shoulder Pain and Disability Index (SPADI), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the presence of metabolic syndrome, using any non-steroidal anti-inflammatory drugs, Pain Catastrophizing Scale (PCS), Illness Perception Questionnaire-revised (IPQ-R), Hospital Anxiety and Depression Scale (HADS), behavioral pattern of the patient, sociodemographic characteristics, and treatment expectancy were outcome measures.ResultsThirteen significant risk factors of having kinesiophobia were: VASat rest (≥ 5.2), VASduring activity (≥ 7.1), DASH (≥ 72.1), presence of metabolic syndrome, PCShelplessness (≥ 16.1), IPQ-Rpersonal control (≤ 17.1), IPQ-Rtreatment control (≤ 16.3), HADSdepression (≥ 7.9), avoidance behavior type, being female, educational level (≤ high school), average hours of sleep (≤ 6.8), and treatment expectancy (≤ 6.6). The presence of seven or more risk factors increased the probability of having high level of kinesiophobia from 34.3 to 51%.Conclusions
It seems necessary to address these factors, increase awareness of health practitioners and individuals.Level of evidenceLevel IV.
Objective
This trial examines the efficacy of the Pain Neuroscience Education (PNE) on clinical outcomes in patients with arthroscopic rotator cuff repair (ARCR).
Design
A total of 36 participants undergoing ARCR were assigned to either the experimental group (n = 18) or control group (n = 18) in this randomized study. A 6-week-long conventional physiotherapy program was administered for both groups. In addition, a PNE protocol was administered for the experimental group for a whole period of 6 weeks (one session/week, 15-60 min per session). The primary outcomes were to compare pre- and post-treatment scores of the experimental versus control groups on the pain and disability. Our secondary outcomes included the comparisons of scores on the catastrophizing, anxiety, depression, kinesiophobia, and quality of life. The participants were assessed both at baseline and post-treatment.
Results
The improvement in pain catastrophizing, anxiety, depression and kinesiophobia was greater in the experimental group (p < 0.05). The improvement was similar in both groups in terms of the rest of outcome measures.
Conclusion
This study showed that the PNE improved only psychological aspects of the chronic pain in ARCR. Therefore, adding PNE to the conventional program might be useful to improve pain catastrophizing, anxiety, depression and kinesiophobia in patients with ARCR.
Objectives
To explore the postoperative kinesophobia of patients after percutaneous coronary intervention (PCI) and its related factors.
Background
Percutaneous coronary intervention is an effective method to treat coronary heart disease (CHD), and cardiac rehabilitation is an important auxiliary method after PCI. However, the compliance of patients with cardiac rehabilitation after PCI is not good, among which kinesophobia is an important influencing factor.
Design
A descriptive cross‐sectional design was implemented, and the high‐quality reporting of the study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology Statement.
Methods
In total, 351 inpatients who underwent PCI in three tertiary grade‐A hospitals in China were selected by convenient sampling method. We use one‐way ANOVA and multiple linear regression analysis to determine the relevant related factors.
Results
The kinesophobia of patients after PCI was negatively correlated with chronic illness resource utilization and sense of personal mastery, and positively correlated with illness perception. Education level, clinical classification of CHD, exercise habits, chronic illness resource utilization, illness perception and sense of personal mastery entered the regression equation, which could explain 78.1% of the total variation.
Conclusion
The level of kinesiophobia of patients after PCI is high. Education level, clinical classification of CHD, exercise habits, chronic illness resource utilization, illness perception and sense of personal mastery are the related factors of kinesiophobia of patients after PCI.
Relevance to Clinical Practice
By reducing the level of exercise fear of patients after PCI, patients are more likely to accept and adhere to the cardiac rehabilitation plan, thus improving their prognosis and improving their quality of life.
Patient or Public Contribution
The patient underwent PCI in the research hospital. Researchers screen them according to the inclusion criteria and invite them to participate in this study. If they meet the requirements, participants will answer the research questionnaire face to face after signing the informed consent form.
Objective
(1) To identify the characteristics of PNE programs in terms of teaching-learning strategies, session modality, content delivery format, number of sessions, total minutes and instructional support material used in patients with chronic musculoskeletal pain, (2) to describe PNE adaptations for patients with different educational levels or cultural backgrounds, and (3) to describe the influence of the patient's educational level or cultural background on the effects of PNE.
Methods
The PRISMA guideline for scoping reviews was followed. Nine databases were systematically searched up to July 8, 2023. Articles that examined clinical or psychosocial variables in adults with chronic musculoskeletal pain who received PNE were included.
Results
Seventy-one articles were included. Studies found benefits of PNE through passive/active teaching-learning strategies with group/individual sessions. However, PNE programs presented great heterogeneity and adaptations to PNE were poorly reported. Most studies did not consider educational level and culture in the effects of PNE.
Conclusions
Despite the large number of studies on PNE and increased interest in this intervention, the educational level and culture are poorly reported in the studies.
Practical implications
It is recommended to use passive and/or active teaching-learning strategies provided in individual and/or group formats considering the patient's educational level and culture.
OBJECTIVE: To explore whether preoperative pain intensity, pain cognitions, and quantitative sensory measures influence the established effectiveness of perioperative pain neuroscience education (PPNE) on health-related quality of life at 1 year after surgery for lumbar radiculopathy.
DESIGN: Secondary analysis of a triple-blinded randomized controlled trial.
METHODS: Participants (n = 90) were Dutch-speaking adults (18-65 years) who were scheduled for surgery for lumbar radiculopathy in 3 Belgian hospitals. They were randomized (1:1) to receive PPNE (n = 41) or perioperative biomedical education (n = 49). Linear mixed models were built for health-related quality of life (ie, SF-6D utility values, Physical and Mental Component of the 36-item Short Form Health Survey) using the following independent variables: therapy, time, and preoperative scores for back and leg pain intensity, pain catastrophizing, kinesiophobia, hypervigilance, and quantitative sensory measures.
RESULTS: The impact of PPNE on SF-6D utility values over time was influenced by kinesiophobia (F = 3.30, P = .02) and leg pain intensity (F = 3.48, P = .02). Regardless of the intervention, back pain intensity negatively influenced SF-6D values over time (F = 3.99, P = .009). The Physical Component scores were negatively impacted by back pain intensity (F = 9.08, P = .003) and were influenced over time by leg pain intensity (F = 2.87, P = .04). The Mental Component scores were negatively impacted by back pain intensity (F = 6.64, P = .01) and pain catastrophizing (F = 5.42, P = .02), as well as hypervigilance (F = 3.16, P = .03) and leg pain intensity (F = 3.12, P = .03) over time.
CONCLUSION: PPNE may be more effective than perioperative biomedical education in improving postoperative health utility values in patients who reported higher kinesiophobia and leg pain intensity before surgery for lumbar radiculopathy. J Orthop Sports Phys Ther 2024;54(4):279-288. Epub 8 January 2024. doi:10.2519/jospt.2024.12051
Introduction
Pain is one of the most persistent symptoms after cancer treatment. The central nervous system can erroneously stay in its alarm phase, altering the pain experience of patients who have cancer. Pain neuroscience education (PNE) with multimodal approaches may benefit these patients.
Objective
This protocol aims to determine the effectiveness of a PNE tool on pain, physical function and quality of life, as a supplement to a multimodal rehabilitation (MR) program in patients who had breast cancer (BC).
Methods
An 8-week double-blinded randomized controlled trial will be conducted, including 72 participants who had BC and who have persistent pain, randomized into three groups: PNE program + MR program, traditional biomedical information + MR program and control group. The PNE program will include educational content that participants will learn through a mobile app and the MR program will include a concurrent exercise program and manual therapy. The primary outcome will be the perceived pain assessed using the Visual Analogue Scale and secondary outcomes are others related to pain, physical function and quality of life. All outcomes will be evaluated at baseline, at the end of the intervention and 6 months after the end of intervention.
Discussion
The proposed study may help BC patients with persistent pain improve their pain experience, quality of life and provide for more adaptive pain-coping strategies. This protocol could propose an action guide to implement different integral approaches for the treatment of sequelae. This treatment option could be offered to this patient profile and it could be easily implemented in the healthcare systems due to its low costs.
Trial registration
ClinicalTrials.gov, NCT04877860. (February18, 2022).
Background and Objective
Pain neuroscience education (PNE) has shown promising ability in previous reviews to improve pain and disability in chronic low back pain (CLBP). This review aimed to evaluate randomised controlled trials comparing the effectiveness of PNE on pain and disability in CLBP.
Databases and Data Treatment
A systematic search was performed using the databases of EBSCO, Medline, Cochrane and Web of Science. Meta‐analysis was performed using the RevMan 5.1 software to pool outcomes using the random effects model, weighted mean differences (WMD), standard deviation, 95% confidence intervals and sample size. GRADEpro software was utilised to calculate overall strength of evidence.
Results
6767 papers were found, 8 were included (n=615). Meta‐analysis for short‐term pain (n=428) demonstrated a WMD of 0.73 (95%CI ‐0.14; 1.61) on a ten‐point scale of PNE against no PNE (GRADE analysis low evidence). When PNE alongside physiotherapy interventions was grouped for pain (n=212), a WMD of 1.32 was demonstrated (95% CI 1.08; 1.56, p<0.00001) (GRADE analysis moderate evidence). Short‐term disability (RMDQ) meta‐analysis demonstrated a WMD of 0.42 (95%CI 0.28; 0.56) (p<0.00001) (n=362) (GRADE analysis moderate evidence); whereas the addition of PNE to physiotherapy interventions demonstrated a WMD of 3.94 (95% CI 3.37; 4.52) (p<0.00001) (GRADE analysis moderate evidence.
Conclusion
This review presents moderate evidence that the addition of PNE to usual physiotherapy intervention in patients with CLBP improves disability in the short‐term. However, this meta‐analysis failed to show evidence of long‐term improvement on pain or disability when adding PNE to usual physiotherapy.
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Conservative, surgical and pharmacological strategies for chronic low back pain (CLBP) management offer at best modest effect sizes in reducing pain and related disability, indicating a need for improvement. Such improvement may be derived from applying contemporary pain neuroscience to the management of CLBP. Current interventions for people with CLBP are often based entirely on a "biomedical" or "psychological" model without consideration of information concerning underlying pain mechanisms and contemporary pain neuroscience. Here we update readers with our current understanding of pain in people with CLBP, showing that CLBP is not limited to spinal impairments, but is also characterised by brain changes, including functional connectivity reorganisation in several brain regions and increased activation in brain regions of the so-called 'pain matrix' (or 'pain connectome'). Indeed, in a subgroup of the CLBP population brain changes associated with the presence of central sensitisation are seen. Understanding the role of these brain changes in CLBP improves our understanding not only of pain symptoms, but also of prevalent CLBP associated comorbidities such as sleep disturbances and fear avoidance behaviour. Applying contemporary pain neuroscience to improve care for people with CLBP includes identifying relevant pain mechanisms to steer intervention, addressing sleep problems and optimising exercise and activity interventions. This approach includes cognitively preparing patients for exercise therapy using (therapeutic) pain neuroscience education, followed by cognition-targeted functional exercise therapy.
Purpose:
The main focus of Pain Neuroscience Education is around changing patients' pain perceptions and minimizing further medical care. Even though Pain Neuroscience Education has been studied extensively, the experiences of patients regarding the Pain Neuroscience Education process remain to be explored. Therefore, the aim of this study was to explore the experiences in patients with non-specific chronic pain.
Materials and methods:
Fifteen patients with non-specific chronic pain from a transdisciplinary treatment centre were in-depth interviewed. Data collection and analysis were performed according to Grounded Theory.
Results:
Five interacting topics emerged: (1) "the pre-Pain Neuroscience Education phase", involving the primary needs to provide Pain Neuroscience Education, with subthemes containing (a) "a broad intake" and (b) "the healthcare professionals"; (2) "a comprehensible Pain Neuroscience Education" containing (a) "understandable explanation" and (b) "interaction between the physiotherapist and psychologist"; (3) "outcomes of Pain Neuroscience Education" including (a) "awareness", b) "finding peace of mind", and (c) "fewer symptoms"; 4) "scepticism" containing (a) "doubt towards the diagnosis and Pain Neuroscience Education", (b) "disagreement with the diagnosis and Pain Neuroscience Education", and (c) "Pain Neuroscience Education can be confronting".
Conclusion:
This is the first study providing insight into the constructs contributing to the Pain Neuroscience Education experience of patients with non-specific chronic pain. The results reveal the importance of the therapeutic alliance between the patient and caregiver, taking time, listening, providing a clear explanation, and the possible outcomes when doing so. The findings from this study can be used to facilitate healthcare professionals in providing Pain Neuroscience Education to patients with non-specific chronic pain. Implications for Rehabilitation An extensive biopsychosocial patient centred intake is crucial prior to providing Pain Neuroscience Education. Repetitions of Pain Neuroscience Education, in different forms (verbal and written information, examples, drawings, etc.) help patients to understand the theory of neurophysiology. Pain Neuroscience Education induces insight into the patient's complaints, improved coping with complaints, improved self-control, and induces in some cases peace of mind. Healthcare professionals providing Pain Neuroscience Education should be aware of the possible confronting nature of the contributing factors.
Chronic musculoskeletal pain (CMP) refers to ongoing pain felt in the bones, joints and tissues of the body that persists longer than 3 months. For these conditions, it is widely accepted that secondary pathologies or the consequences of persistent pain, including fear of movement, pain catastrophizing, anxiety and nervous system sensitization appear to be the main contributors to pain and disability. While exercise is a primary treatment modality for CMP, the intent is often to improve physical function with less attention to secondary pathologies. Exercise interventions for CMP which address secondary pathologies align with contemporary pain rehabilitation practices and have greater potential to improve patient outcomes above exercise alone. Biopsychosocial treatment which acknowledges and addresses the biological, psychological and social contributions to pain and disability is currently seen as the most efficacious approach to chronic pain. This clinical update discusses key aspects of a biopsychosocial approach concerning exercise prescription for CMP and considers both patient needs and clinician competencies. There is consensus for individualized, supervised exercise based on patient presentation, goals and preference that is perceived as safe and non‐threatening to avoid fostering unhelpful associations between physical activity and pain. The weight of evidence supporting exercise for CMP has been provided by aerobic and resistance exercise studies, although there is considerable uncertainty on how to best apply the findings to exercise prescription. In this clinical update, we also provide evidence‐based guidance on exercise prescription for CMP through a synthesis of published work within the field of exercise and CMP rehabilitation.
In recent years, there has been an increased interest in pain neuroscience education (PNE) in physical therapy. There is growing evidence for the efficacy of PNE to decrease pain, disability, fear-avoidance, pain catastrophization, limited movement, and health care utilization in people struggling with pain. PNE teaches people in pain more about the biology and physiology of their pain experience including processes such as central sensitization, peripheral sensitization, allodynia, inhibition, facilitation, neuroplasticity and more. PNE’s neurobiological model often finds itself at odds with traditional biomedical models used in physical therapy. Traditional biomedical models, focusing on anatomy, pathoanatomy, and biomechanics have been shown to have limited efficacy in helping people understand their pain, especially chronic pain, and may in fact even increase a person’s pain experience by increasing fear-avoidance and pain catastrophization. An area of physical therapy where the biomedical model is used a lot is manual therapy. This contrast between PNE and manual therapy has seemingly polarized followers from each approach to see PNE as a ‘hands-off’ approach even having clinicians categorize patients as either in need of receiving PNE (with no hands-on), or hands-on with no PNE. In this paper, we explore the notion of PNE and manual therapy co-existing. PNE research has shown to have immediate effects of various clinical signs and symptoms associated with central sensitization. Using a model of sensitization (innocuous, noxious, and allodynia), we argue that PNE can be used in a manual therapy model, especially treating someone where the nervous system has become increasingly hypervigilant.
Level of Evidence: VII
We conducted a systematic review of guidelines on the management of low back pain (LBP) to assess their methodological quality and guide care. We synthesized guidelines on the management of LBP published from 2005 to 2014 following best evidence synthesis principles. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane, DARE, National Health Services Economic Evaluation Database, Health Technology Assessment Database, Index to Chiropractic Literature and grey literature. Independent reviewers critically appraised eligible guidelines using AGREE II criteria. We screened 2504 citations; 13 guidelines were eligible for critical appraisal, and 10 had a low risk of bias. According to high-quality guidelines: (1) all patients with acute or chronic LBP should receive education, reassurance and instruction on self-management options; (2) patients with acute LBP should be encouraged to return to activity and may benefit from paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or spinal manipulation; (3) the management of chronic LBP may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment); and (4) patients with lumbar disc herniation with radiculopathy may benefit from spinal manipulation. Ten guidelines were of high methodological quality, but updating and some methodological improvements are needed. Overall, most guidelines target nonspecific LBP and recommend education, staying active/exercise, manual therapy, and paracetamol or NSAIDs as first-line treatments. The recommendation to use paracetamol for acute LBP is challenged by recent evidence and needs to be revisited.
Significance:
Most high-quality guidelines recommend education, staying active/exercise, manual therapy and paracetamol/NSAIDs as first-line treatments for LBP. Recommendation of paracetamol for acute LBP is challenged by recent evidence and needs updating.
Purpose
The Tampa Scale of Kinesiophobia (TSK) is a commonly used measure for the assessment of kinesiophobia related to spinal diseases. The Italian version showed satisfactory psychometric properties, but its responsiveness has not yet been evaluated. This observational study is aimed at evaluating the responsiveness and minimal important changes (MICs) for the TSK in subjects with chronic low back pain.
Methods
At the beginning and end of an 8-week multidisciplinary rehabilitation programme, 205 patients completed the TSK. After the programme, patients also completed the global perceived effect (GPE) scale, which was divided to produce a dichotomous outcome. Responsiveness was calculated by distribution [effect size (ES); standardised response mean (SRM)] and anchor-based methods [receiver-operating characteristics (ROC) curves; correlations between change scores of the TSK and GPE]. ROC curves were also used to compute the best cut-off levels between subjects with a “good” or “poor” outcome (MICs).
Results
The ES and the SRM were 1.49 and 1.36, respectively. The ROC analyses revealed a MIC value (AUC; sensitivity; specificity) of 5.5 (0.996; 95; 97). To avoid any dependence on the baseline scores, the MIC value [area under the curve (AUC); sensitivity; and specificity] was computed also based on the percentage of change from the baseline and a value of 18 % (0.998; 97; 98 %) was obtained. The correlation between change scores of the TSK and GPE was high (0.871).
Conclusions
The TSK was sensitive in detecting clinical changes in subjects with chronic low back pain. We recommend taking the MICs provided into account when assessing patients’ improvement or planning studies in this clinical context.
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.
Teaching people about the neurobiology and neurophysiology of their pain experience has a therapeutic effect and has been referred to as pain neuroscience education (PNE). Various high-quality randomized controlled trials and systematic reviews have shown increasing efficacy of PNE decreasing pain, disability, pain catastrophization, movement restrictions, and healthcare utilization. Research studies, however, by virtue of their design, are very controlled environments and, therefore, in contrast to the ever-increasing evidence for PNE, little is known about the clinical application of this emerging therapy. In contrast, case studies, case series, and expert opinion and perspectives by authorities in the world of pain science provide clinicians with a glimpse into potential “real” clinical application of PNE in the face of the ever-increasing chronic pain epidemic. By taking the material from the randomized controlled trials, systematic reviews, case series, case studies, and expert opinion, this article aims to provide a proposed layout of the clinical application of PNE. The article systematically discusses key elements of PNE including examination, educational content, and delivery methods, merging of PNE with movement, goal setting, and progression. This perspectives article concludes with a call for research into the clinical application of PNE.
Objective:
To determine if a 3-hour therapeutic neuroscience education session alters physical therapy student's knowledge of pain and effects their attitudes and beliefs regarding treating chronic pain.
Methods:
Seventy-seven entry-level doctoral physical therapy students participated in the study. Following consent, demographic data were obtained and then the subjects completed the Neuroscience of Pain Questionnaire, the Health Care Provider's Pain and Impairment Relationship Scale and an additional questionnaire designed by the researchers. The subjects then received a 3-hour educational session developed by the researchers, focusing on the neurobiology and physiology of pain. The questionnaires were re-administered immediately after the educational session and at 6 months post-education.
Results:
Seventy-seven subjects (mean age = 24.7 years, 57.1% female and 81.8% white) completed the questionnaires pre- and post-educational session with 75 completing the questionnaires at 6 months. To assess the effect of the education on the scores of the questionnaires, a repeated measures ANOVA was conducted. Students demonstrated significantly higher scores on the neuroscience of pain questionnaire (p < 0.001) with no significant effect found on the attitudes and beliefs questionnaire at any of the time points. There were significant differences found on some of the individual questions that were part of the additional questionnaire.
Discussion:
An educational session on the neuroscience of pain is beneficial for educating entry-level doctoral physical therapy students immediately post-education and at 6 months. This educational session had no effect on the student's attitudes and beliefs regarding treating the chronic pain population. There were additional significant findings regarding individual questions posed to the subjects.
Background:
Chronic pain can contribute to disability, depression, anxiety, sleep disturbances, poor quality of life and increased health care costs, with close to 20 % of the adult population in Europe reporting chronic pain. To empower the person to self-manage, it is advocated that education and training about the nature of pain and its effects and how to live with pain is provided. The objective of this review is to determine the level of evidence for education to facilitate knowledge about chronic pain, delivered as a stand-alone intervention for adults, to reduce pain and disability.
Methods:
We identified randomised controlled trials of educational intervention for chronic pain by searching CENTRAL, MEDLINE, EMBASE and ongoing trials registries (inception to December 2013). Main inclusion criteria were (1) pain >3 months; (2) study design that allowed isolation of effects of education and (3) measures of pain or disability. Two reviewers independently screened and appraised each study.
Results:
Nine studies were analysed. Pooled data from five studies, where the comparator group was usual care, showed no improvement in pain or disability. In the other four studies, comparing different types of education, there was no evidence for an improvement in pain; although, there was evidence (from one study) of a decrease in disability with a particular form of education-pain neurophysiology education (PNE). Post-hoc analysis of psychosocial outcomes reported in the studies showed evidence of a reduction in catastrophising and an increase of knowledge about pain following PNE.
Conclusions:
The evidence base is limited by the small numbers of studies, their relatively small sample sizes, and the diversity in types of education studied. From that limited evidence, the only support for this type of education is for PNE, though it is insufficiently strong to recommend conclusively that PNE should be delivered as a stand-alone intervention. It therefore remains sensible to recommend that education be delivered in conjunction with other pain management approaches as we cannot confidently conclude that education alone is effective in reducing pain intensity or related disability in chronic pain in adults.
Background:
Among the multiple conservative modalities, physiotherapy is a commonly utilized treatment modality in managing chronic non-specific spinal pain. Despite the scientific progresses with regard to pain and motor control neuroscience, treatment of chronic spinal pain (CSP) often tends to stick to a peripheral biomechanical model, without targeting brain mechanisms. With a view to enhance clinical efficacy of existing physiotherapeutic treatments for CSP, the development of clinical strategies targeted at 'training the brain' is to be pursued. Promising proof-of-principle results have been reported for the effectiveness of a modern neuroscience approach to CSP when compared to usual care, but confirmation is required in a larger, multi-center trial with appropriate evidence-based control intervention and long-term follow-up.The aim of this study is to assess the effectiveness of a modern neuroscience approach, compared to usual care evidence-based physiotherapy, for reducing pain and improving functioning in patients with CSP. A secondary objective entails examining the effectiveness of the modern neuroscience approach versus usual care physiotherapy for normalizing brain gray matter in patients with CSP.
Methods/design:
The study is a multi-center, triple-blind, two-arm (1:1) randomized clinical trial with 1-year follow-up. 120 CSP patients will be randomly allocated to either the experimental (receiving pain neuroscience education followed by cognition-targeted motor control training) or the control group (receiving usual care physiotherapy), each comprising of 3 months treatment. The main outcome measures are pain (including symptoms and indices of central sensitization) and self-reported disability. Secondary outcome measures include brain gray matter structure, motor control, muscle properties, and psychosocial correlates. Clinical assessment and brain imaging will be performed at baseline, post-treatment and at 1-year follow-up. Web-based questionnaires will be completed at baseline, after the first 3 treatment sessions, post-treatment, and at 6 and 12-months follow-up.
Discussion:
Findings may provide empirical evidence on: (1) the effectiveness of a modern neuroscience approach to CSP for reducing pain and improving functioning, (2) the effectiveness of a modern neuroscience approach for normalizing brain gray matter in CSP patients, and (3) factors associated with therapy success. Hence, this trial might contribute towards refining guidelines for good clinical practice and might be used as a basis for health authorities' recommendations.
Trial registration:
ClinicalTrials.gov Identifier: NCT02098005.
To estimate the global burden of low back pain (LBP).
LBP was defined as pain in the area on the posterior aspect of the body from the lower margin of the twelfth ribs to the lower glutaeal folds with or without pain referred into one or both lower limbs that lasts for at least one day. Systematic reviews were performed of the prevalence, incidence, remission, duration, and mortality risk of LBP. Four levels of severity were identified for LBP with and without leg pain, each with their own disability weights. The disability weights were applied to prevalence values to derive the overall disability of LBP expressed as years lived with disability (YLDs). As there is no mortality from LBP, YLDs are the same as disability-adjusted life years (DALYs).
Out of all 291 conditions studied in the Global Burden of Disease 2010 Study, LBP ranked highest in terms of disability (YLDs), and sixth in terms of overall burden (DALYs). The global point prevalence of LBP was 9.4% (95% CI 9.0 to 9.8). DALYs increased from 58.2 million (M) (95% CI 39.9M to 78.1M) in 1990 to 83.0M (95% CI 56.6M to 111.9M) in 2010. Prevalence and burden increased with age.
LBP causes more global disability than any other condition. With the ageing population, there is an urgent need for further research to better understand LBP across different settings.
This paper summarizes the results of 244 correlates of national IQs that have been published from 2002 through 2012 and include educational attainment, cognitive output, educational input, per capita income, economic growth, other economic variables, crime, political institutions, health, fertility, sociological variables, and geographic and climatic variables.
This paper presents a revised version of the Illness Perception Questionnaire (IPQ-R), a recently developed and widely used quantitative measure of the five components of illness representations in Leventhal's self-regulatory model. The revised version stemmed from a need to deal with minor psychometric problems with two subscales, and to include additional subscales, assessing cyclical timeline perceptions, illness coherence, and emotional representations. Item selection was determined by principal components analyses which verified the factorial structure of the questionnaire in a sample of 711 patients from 8 different illness groups. Further analysis provided good evidence for both the internal reliability of the subscales and the short (3 week) and longer term (6 month) retest reliability. The IPQ-R also demonstrated sound discriminant, known group and predictive validity. While it is possible that the new subscales will vary in their applicability in different patient groups, the IPQ-R provides a more comprehensive and psychometrically acceptable assessment of the key components of patients' perceptions of illness.
In Study 1, the Pain Catastrophizing Scale (PCS) was administered to 425 undergraduates. Analyses yielded a three component solution comprising (a) rumination, (b) magnification, and (c) helplessness. In Study 2, 30 undergraduate participants were classified as catastrophizers (n = 15) or noncatastrophizers (n = 15) on the basis of their PCS scores and participated in an cold pressor procedure. Catastrophizers reported significantly more negative pain-related thoughts, greater emotional distress, and greater pain intensity than noncatastrophizers. Study 3 examined the relation between PCS scores, negative pain-related thoughts, and distress in 28 individuals undergoing an aversive electrodiagnostic medical procedure. Catastrophizers reported more negative pain-related thoughts, more emotional distress, and more pain than noncatastrophizers. Study 4 examined the relation between the PCS and measures of depression, trait anxiety, negative affectivity, and fear of pain. Analyses revealed moderate correlations among these measures, but only the PCS contributed significant unique variance to the prediction of pain intensity.
It is well established that the biomedical model falls short in explaining chronic musculoskeletal pain. Although many musculoskeletal therapists have moved on in their thinking and apply a broad biopsychosocial view with regard to chronic pain disorders, the majority of clinicians have received a biomedical-focused training/education. Such a biomedical training is likely to influence the therapists' attitudes and core beliefs toward chronic musculoskeletal pain. Therapists should be aware of the impact of their own attitudes and beliefs on the patient's attitudes and beliefs. As patient's attitudes and beliefs influence treatment adherence, musculoskeletal therapists should be aware that focusing on the biomedical model for chronic musculoskeletal pain is likely to result in poor compliance with evidence based treatment guidelines, less treatment adherence and a poorer treatment outcome. Here, we provide clinicians with a 5-step approach toward effective and evidence-based care for patients with chronic musculoskeletal pain. The starting point entails self-reflection: musculoskeletal therapists can easily self-assess their attitudes and beliefs regarding chronic musculoskeletal pain. Once the therapist holds evidence-based attitudes and beliefs regarding chronic musculoskeletal pain, assessing patients' attitudes and beliefs will be the natural next step. Such information can be integrated in the clinical reasoning process, which in turn results in individually-tailored treatment programs that specifically address the patients' attitudes and beliefs in order to improve treatment adherence and outcome.
Background: Measuring disease and injury burden in populations requires a composite metric that captures both premature mortality and the prevalence and severity of ill-health. The 1990 Global Burden of Disease study proposed disability-adjusted life years (DALYs) to measure disease burden. No comprehensive update of disease burden worldwide incorporating a systematic reassessment of disease and injury-specific epidemiology has been done since the 1990 study. We aimed to calculate disease burden worldwide and for 21 regions for 1990, 2005, and 2010 with methods to enable meaningful comparisons over time.
Methods: We calculated DALYs as the sum of years of life lost (YLLs) and years lived with disability (YLDs). DALYs were calculated for 291 causes, 20 age groups, both sexes, and for 187 countries, and aggregated to regional and global estimates of disease burden for three points in time with strictly comparable definitions and methods. YLLs were calculated from age-sex-country-time-specific estimates of mortality by cause, with death by standardised lost life expectancy at each age. YLDs were calculated as prevalence of 1160 disabling sequelae, by age, sex, and cause, and weighted by new disability weights for each health state. Neither YLLs nor YLDs were age-weighted or discounted. Uncertainty around cause-specific DALYs was calculated incorporating uncertainty in levels of all-cause mortality, cause-specific mortality, prevalence, and disability weights.
Findings: Global DALYs remained stable from 1990 (2·503 billion) to 2010 (2·490 billion). Crude DALYs per 1000 decreased by 23% (472 per 1000 to 361 per 1000). An important shift has occurred in DALY composition with the contribution of deaths and disability among children (younger than 5 years of age) declining from 41% of global DALYs in 1990 to 25% in 2010. YLLs typically account for about half of disease burden in more developed regions (high-income Asia Pacific, western Europe, high-income North America, and Australasia), rising to over 80% of DALYs in sub-Saharan Africa. In 1990, 47% of DALYs worldwide were from communicable, maternal, neonatal, and nutritional disorders, 43% from non-communicable diseases, and 10% from injuries. By 2010, this had shifted to 35%, 54%, and 11%, respectively. Ischaemic heart disease was the leading cause of DALYs worldwide in 2010 (up from fourth rank in 1990, increasing by 29%), followed by lower respiratory infections (top rank in 1990; 44% decline in DALYs), stroke (fifth in 1990; 19% increase), diarrhoeal diseases (second in 1990; 51% decrease), and HIV/AIDS (33rd in 1990; 351% increase). Major depressive disorder increased from 15th to 11th rank (37% increase) and road injury from 12th to 10th rank (34% increase). Substantial heterogeneity exists in rankings of leading causes of disease burden among regions.
Interpretation: Global disease burden has continued to shift away from communicable to non-communicable diseases and from premature death to years lived with disability. In sub-Saharan Africa, however, many communicable, maternal, neonatal, and nutritional disorders remain the dominant causes of disease burden. The rising burden from mental and behavioural disorders, musculoskeletal disorders, and diabetes will impose new challenges on health systems. Regional heterogeneity highlights the importance of understanding local burden of disease and setting goals and targets for the post-2015 agenda taking such patterns into account. Because of improved definitions, methods, and data, these results for 1990 and 2010 supersede all previously published Global Burden of Disease results.
Funding: Bill & Melinda Gates Foundation.
Objectives:
To determine why some people develop chronic low back pain, and whether illness perceptions are an important risk factor in the transition from acute to chronic low back pain.
Design:
Cross-sectional study.
Participants:
Four hundred and two members of the general Dutch population, with and without chronic low back pain.
Main outcome measures:
Sociodemographics and the translated version of the illness perception questionnaire-revised, adapted for back pain.
Results:
Of the sample, 115 (29%) individuals had chronic low back pain (>6 months) and 287 (71%) did not have chronic low back pain. Many of the participants with chronic low back pain believed that one 'wrong' movement can potentially lead to more severe problems, and that X-rays or computer tomography scans can determine the cause of the pain. Many of the participants with chronic low back pain did not perceive a relationship between psychosocial factors and low back pain.
Conclusions:
Illness perceptions differed between individuals with and without chronic low back pain. In the subacute phase, healthcare professionals could assess illness perceptions and, if necessary, incorporate them into the management of patients with low back pain.
In Study I, the Pain Catastrophizing Scale (PCS) was administered to 425 undergraduates. Analyses yielded a three component solution comprising (a) rumination, (b) magnification, and (c) helplessness. In Study 2, 30 undergraduate participants were classified as catastrophizers (
n = 15) or noncatastrophizers (
n = 15) on the basis of their PCS scores and participated in a cold pressor procedure. Catastrophizers reported significantly more negative pain-related thoughts, greater emotional distress, and greater pain intensity than noncatastrophizers. Study 3 examined the relation between PCS scores, negative pain-related thoughts, and distress in 28 individuals undergoing an aversive electrodiagnostic medical procedure. Catastrophizers reported more negative pain-related thoughts, more emotional distress, and more pain than noncatastrophizers. Study 4 examined the relation between the PCS and measures of depression, trait anxiety, negative affectivity, and fear of pain. Analyses revealed moderate correlations among these measures, but only the PCS contributed significant unique variance to the prediction of pain intensity. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This 5-year prospective longitudinal study of 70,000 + English children examined the association between psychometric intelligence at age 11 years and educational achievement in national examinations in 25 academic subjects at age 16. The correlation between a latent intelligence trait (Spearman's g from CAT2E) and a latent trait of educational achievement (GCSE scores) was 0.81. General intelligence contributed to success on all 25 subjects. Variance accounted for ranged from 58.6% in Mathematics and 48% in English to 18.1% in Art and Design. Girls showed no advantage in g, but performed significantly better on all subjects except Physics. This was not due to their better verbal ability. At age 16, obtaining five or more GCSEs at grades A⁎–C is an important criterion. 61% of girls and 50% of boys achieved this. For those at the mean level of g at age 11, 58% achieved this; a standard deviation increase or decrease in g altered the values to 91% and 16%, respectively.
To explore the change in kinesiophobia in relation to activity limitation after a multidisciplinary rehabilitation programme in patients with chronic back pain.
A prospective cohort study was made including 265 patients. Data were collected at baseline, after rehabilitation, and at 6-months follow-up. Outcome measures were the Tampa Scale for kinesiophobia (TSK) and the disability rating index (DRI). The smallest detectable change (SDC) in TSK was set to 8 scores. Relationships between kinesiophobia and activity limitation/physical ability were explored with regard to subgroups with high, medium and low baseline TSK scores, and for those patients who did or did not reach the SDC in TSK.
Improvements in TSK showed high effect sizes in the groups with high and medium baseline TSK scores. Improvements in DRI showed medium effect sizes in all three TSK subgroups. One third of the patients reached the SDC in TSK, and this group also improved significantly more in DRI. The correlation between change in TSK and change in DRI was low. Half of the patients with high TSK score at baseline remained having high DRI at follow-up.
Improvement in physical ability was not related to the initial degree of kinesiophobia but to the SDC in TSK. To prevent patients with high kinesiophobia from preserving high activity limitations, it might be useful to include targeted treatment of kinesiophobia.
For patients with low back pain, fear-avoidance beliefs (FABs) represent cognitions and emotions that underpin concerns and fears about the potential for physical activities to produce pain and further harm to the spine. Excessive FABs result in heightened disability and are an obstacle for recovery from acute, subacute, and chronic low back pain.
This article summarizes past research concerning the etiology, impact, and assessment of FABs; reviews the results and relevance to clinical practice of trials that have addressed FAB as part of low back pain treatment; and lists areas in need of further study.
This article reports on a plenary presentation and discussion of an expert panel and workshop entitled "Addressing fear-avoidance beliefs in a fear-avoidant world--translating research into clinical practice" that was held at Forum X, Primary Care Research on Low Back Pain, during June 2009, at the Harvard School of Public Health in Boston, MA, USA.
Important issues including the definition, etiology, impact, and treatment of FAB on low back pain outcomes were reviewed by six panelists with extensive experience in FAB-related research. This was followed by a group discussion among 40 attendees. Conclusion and recommendations were extracted by the workshop panelist and summarized in this article.
Fear-avoidance beliefs are derived from both emotionally based fears of pain and injury and information-based beliefs about the soundness of the spine, causes of spine degeneration, and importance of pain. Excessively elevated FABs, both in patients and treating health care providers, have a negative impact on low back pain outcomes as they delay recovery and heighten disability. Fear-avoidance beliefs may be best understood when patients are categorized into subgroups of misinformed avoiders, learned pain avoiders, and affective avoiders as these categories elucidate potential treatment strategies. These include FAB-reducing information for misinformed avoiders, pain desensitizing treatments for pain avoiders, and fear desensitization along with counseling to address the negative cognition in affective avoiders. Although mixed results have been noted, most clinical trials have documented improved outcomes when FAB is addressed as part of treatment. Deficiencies in knowledge about brief methods for assessing FAB during clinical encounters, the importance of medical explanations for back pain, usefulness of subgroup FABs, core points for information-based treatments, and efficient strategies for transferring FAB-reducing information to patients hamper the translation of FAB research into clinical practice.
By incorporating an understanding of FAB, clinicians may enhance their ability to assess the predicaments of their patients with low back pain and gain insight into potential value of corrective information that lessen fears and concerns on well-being of their patients.
Chronic whiplash is a debilitating condition characterized by increased sensitivity to painful stimuli, maladaptive illness beliefs, inappropriate attitudes, and movement dysfunctions. Previous work in people with chronic low back pain and chronic fatigue syndrome indicates that pain neurophysiology education is able to improve illness beliefs and attitudes as well as movement performance. This single-case study (A-B-C design) with six patients with chronic whiplash associated disorders (WAD) was aimed at examining whether education about the neurophysiology of pain is accompanied by changes in symptoms, daily functioning, pain beliefs, and behavior. Periods A and C represented assessment periods, while period B consisted of the intervention (pain neurophysiology education). Results showed a significant decrease in kinesiophobia (Tampa Scale for Kinesiophobia), the passive coping strategy of resting (Pain Coping Inventory), self-rated disability (Neck Disability Index), and photophobia (WAD Symptom List). At the same time, significantly increased pain pressure thresholds and improved pain-free movement performance (visual analog scale on Neck Extension Test and Brachial Plexus Provocation Test) were established. Although the current results need to be verified in a randomized, controlled trial, they suggest that education about the physiology of pain is able to increase pain thresholds and improve pain behavior and pain-free movement performance in patients with chronic WAD.
Background:
The Pain Catastrophizing Scale (PCS), a widely used tool to assess catastrophizing related to spinal disorders, shows valid psychometric properties in general but the minimal important change (MIC) is still not determined.
Design:
Prospective observational study.
Aim:
To assess responsiveness and MIC of the PCS in individuals with chronic low back pain (LBP) undergoing multidisciplinary rehabilitation.
Setting:
Outpatient rehabilitation hospital.
Population:
Two hundred and five patients with chronic LBP.
Methods:
Before and after an 8-week multidisciplinary rehabilitation program, 205 patients completed the Italian version of the PCS (PCS-I). We calculated the PCS-I responsiveness by distribution-based methods [effect size, ES; standardised response mean, SRM; minimum detectable change, MDC] and anchor-based methods [receiver operating characteristic (ROC) curves]. After the program, participants completed a 7-point global perceived effect scale (GPE), based on which they were classified as "improved" vs. "stable". ROC curves computed the best cut-off level (taken as the MIC) between the two groups. ROC analysis was also performed on subgroups according to patients' baseline PCS scores.
Result:
ES, SRM and MDC were 0.71, 0.67 and 7.73, respectively. ROC analysis yielded an MIC of 8 points (95% confidence interval [CI]: 6-10; area under the curve [AUC]: 0.88). ROC analysis of the PCS subgroups confirmed an MIC of 8 points (95%CI: 6-10) for no/low catastrophizers (score <30, n=159; AUC: 0.90) and indicated an MIC of 11 points (95%CI: 8-14) for catastrophizers (score >30, n=33; AUC: 0.84).
Conclusions:
The PCS-I showed good ability to detect patient-perceived clinical changes in chronic LBP post-rehabilitation. The MIC values we determined provide a benchmark for assessing individual improvement in this clinical context.
Clinical rehabilitation impact:
The present study calculated - in a sample of people with chronic LBP - the responsiveness and MIC of the PCS. These values increase confidence in interpreting score changes, enhancing their meaningfulness for both research and clinical contexts.
Background
Pain education is an important part of multidisciplinary management of chronic pain. The characteristics of people likely to have the most improvement in pain biology knowledge following pain education are unknown.
Objective
To identify baseline factors predicting changes in pain biology knowledge in adults with chronic pain following a 2‐hour multidisciplinary pain education session.
Methods
Fifty‐five adults with chronic pain attended a 2‐hour pain education session prior to a multidisciplinary assessment at a pain clinic. Patients completed the 12‐item revised Neurophysiology of Pain Questionnaire (rNPQ, score /12) before and after the pain education session. The primary outcome was change in pain biology knowledge, evaluated with the change in rNPQ score. Ten preselected predictors were investigated using univariate models followed by multivariable models with a manual forwards‐building process.
Results
Education level and age were significantly associated with change in rNPQ in the univariate models. Participants with higher levels of education had, on average, 1.96 (0.68 to 3.23) points more improvement in rNPQ score than those with lower levels of education. For every 10 years older a participant was, their rNPQ scores changed on average by 0.5 (0.1 to 0.8) points less. In the multivariable model, only education level remained significant, explaining 17% of the variance (R² =0.17). Clinical variables assessed (pain severity, pain interference, pain self‐efficacy, depression, anxiety, and pain catastrophizing) did not predict knowledge change.
Conclusion
This study suggests that, of those patients with chronic pain who choose to attend pain education, more educated patients are more likely to improve their pain biology knowledge after a pain education session.
This article is protected by copyright. All rights reserved.
Importance
Effective treatments for chronic spinal pain are essential to reduce the related high personal and socioeconomic costs.
Objective
To compare pain neuroscience education combined with cognition-targeted motor control training with current best-evidence physiotherapy for reducing pain and improving functionality, gray matter morphologic features, and pain cognitions in individuals with chronic spinal pain.
Design, Setting, and Participants
Multicenter randomized clinical trial conducted from January 1, 2014, to January 30, 2017, among 120 patients with chronic nonspecific spinal pain in 2 outpatient hospitals with follow-up at 3, 6, and 12 months.
Interventions
Participants were randomized into an experimental group (combined pain neuroscience education and cognition-targeted motor control training) and a control group (combining education on back and neck pain and general exercise therapy).
Main Outcomes and Measures
Primary outcomes were pain (pressure pain thresholds, numeric rating scale, and central sensitization inventory) and function (pain disability index and mental health and physical health).
Results
There were 22 men and 38 women in the experimental group (mean [SD] age, 39.9 [12.0] years) and 25 men and 35 women in the control group (mean [SD] age, 40.5 [12.9] years). Participants in the experimental group experienced reduced pain (small to medium effect sizes): higher pressure pain thresholds at primary test site at 3 months (estimated marginal [EM] mean, 0.971; 95% CI, –0.028 to 1.970) and reduced central sensitization inventory scores at 6 months (EM mean, –5.684; 95% CI, –10.589 to –0.780) and 12 months (EM mean, –6.053; 95% CI, –10.781 to –1.324). They also experienced improved function (small to medium effect sizes): significant and clinically relevant reduction of disability at 3 months (EM mean, –5.113; 95% CI, –9.994 to –0.232), 6 months (EM mean, –6.351; 95% CI, –11.153 to –1.550), and 12 months (EM mean, –5.779; 95% CI, –10.340 to –1.217); better mental health at 6 months (EM mean, 36.496; 95% CI, 7.998-64.995); and better physical health at 3 months (EM mean, 39.263; 95% CI, 9.644-66.882), 6 months (EM mean, 53.007; 95% CI, 23.805-82.209), and 12 months (EM mean, 32.208; 95% CI, 2.402-62.014).
Conclusions and Relevance
Pain neuroscience education combined with cognition-targeted motor control training appears to be more effective than current best-evidence physiotherapy for improving pain, symptoms of central sensitization, disability, mental and physical functioning, and pain cognitions in individuals with chronic spinal pain. Significant clinical improvements without detectable changes in brain gray matter morphologic features calls into question the relevance of brain gray matter alterations in this population.
Trial Registration
clinicaltrials.gov Identifier: NCT02098005
Introduction:
Chronic pain due to musculoskeletal disorders is the leading cause of disability among older adults and is associated with a lower quality of life, reduced function, and increased risk of institutionalization. Pain Neuroscience Education (PNE) has demonstrated effectiveness in reducing pain and improving pain self-efficacy in individuals under 60 years of age, but there is a paucity of research examining its use with older adults. If PNE has similar effects in older adults, it has the potential to be a useful non-pharmacological intervention for this population.
Methods:
This quasi-experimental feasibility study included 25 subjects over the age of 65 with a 3 month or greater history of lower back and/or lower extremity pain. Subjects participated in two semi-standardized one-on-one PNE sessions and were asked to read a booklet (Why Do I Hurt, Louw, International Spine and Pain Institute, USA) in between sessions. Subjects' perception of PNE was measured after the second session and gait speed, pain disability, and fear of movement were measured pre- and post-PNE.
Results:
Subjects consistently reported a positive experience with PNE. There were statically significant positive improvements in gait speed, pain disability, and fear of movement after the intervention.
Conclusion:
PNE is a feasible and potentially efficacious treatment for older adults with chronic pain.
Objective:
To evaluate the effect of Neurophysiological Pain-Education (NPE) for patients with Chronic Low Back Pain (CLBP).
Methods:
A systematic search was performed in six electronic databases. Eligible RCTs were those with at least 50 % of patients with CLBP and in which NPE was compared with no intervention or usual care. Methodological quality was assessed independently by two of the authors using the Cochrane Collaboration Risk of Bias Tool. The effect of NPE was summarized in a random effect meta-analysis for pain, disability and behavioral attitudes. Effect was estimated as weighted mean difference (WMD) if outcomes were on the same scale or as standardized mean difference (SMD). The overall quality of evidence was evaluated according to GRADE guidelines.
Results:
Seven RCT studies (six low and one high quality) were included. Statistically significant differences in pain, in favor of NPE, were found after treatment, WMD=-1.03 (95%CI -0.55; -1.52), and after 3 months, WMD=-1.09 (-2.17; 0.00). Furthermore statistically significant lower disability was found in the NPE group after treatment, SMD=-0.47 (-0.80; -0.13) and after 3 months SMD=-0.38 (-0.74; -0.02). The difference in favor of NPE in reduction in Tampa Scale of Kinesiophobia was not statistically significant, WMD=-5.73 (-13.60; 2.14) and after 3 months WMD=-0.94 (-6.28; 4.40).
Discussion:
There was moderate evidence supporting the hypothesis that NPE has a small to moderate effect on pain and low evidence of a small to moderate effect on disability immediately after the intervention. NPE has a small to moderate effect on pain and disability at 3 months follow-up in patients with CLBP.
Background:
Available evidence favors the use of pain neuroscience education (PNE) in patients with chronic pain. However, PNE trials are often limited to small sample sizes and, despite the current digital era, the effects of blended-learning PNE (ie, the combination of online digital media with traditional educational methods) have not yet been investigated.
Objective:
The study objective was to examine whether blended-learning PNE is able to improve disability, catastrophizing, kinesiophobia, and illness perceptions.
Design:
This study was a 2-center, triple-blind randomized controlled trial (participants, statistician, and outcome assessor were masked).
Setting:
The study took place at university hospitals in Ghent and Brussels, Belgium.
Participants:
Participants were 120 people with nonspecific chronic spinal pain (ie, chronic neck pain and low back pain).
Intervention:
The intervention was 3 sessions of PNE or biomedically focused back/neck school education (addressing spinal anatomy and physiology).
Measurements:
Measurements were self-report questionnaires (Pain Disability Index, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, Illness Perception Questionnaire, and Pain Vigilance and Awareness Questionnaire).
Results:
None of the treatment groups showed a significant change in the perceived disability (Pain Disability Index) due to pain (mean group difference posteducation: 1.84; 95% CI = -2.80 to 6.47). Significant interaction effects were seen for kinesiophobia and several subscales of the Illness Perception Questionnaire, including negative consequences, cyclical time line, and acute/chronic time line. In-depth analysis revealed that only in the PNE group were these outcomes significantly improved (9% to 17% improvement; 0.37 ≤ Cohen d ≥ 0.86).
Limitations:
Effect sizes are small to moderate, which might raise the concern of limited clinical utility; however, changes in kinesiophobia exceed the minimal detectable difference. PNE should not be used as the sole treatment modality but should be combined with other treatment strategies.
Conclusions:
Blended-learning PNE was able to improve kinesiophobia and illness perceptions in participants with chronic spinal pain. As effect sizes remained small to medium, PNE should not be used as a sole treatment but rather should be used as a key element within a comprehensive active rehabilitation program. Future studies should compare the effects of blended-learning PNE with offline PNE and should consider cost-effectiveness.
ABSTRACT
Aim: To assess the effect of a pain neurophysiology education program plus therapeutic exercise for patients with chronic low back pain (CLBP).
Design: Single-blind randomized controlled trial.
Setting: Private clinic (Clínica Bonn) and Alcalá de Henares University, Madrid, Spain.
Participants: 56 patients with CLBP for 6 months or more.
Intervention: Participants were randomized to receive either a therapeutic exercise (TE) program consisting of motor control, stretching, and aerobic exercises (TE group, n=28) or the same therapeutic exercise program in addition to a pain neurophysiology education program (PNE+TE group, n=28), conducted in two 30 to 50 minute sessions in groups of 4 to 6 participants.
Main outcomes measures: The primary outcome was pain intensity rated on the Numeric Pain Rating Scale which was completed immediately following treatment and at a 1-month and 3-month follow-up. Secondary outcome measures were pressure pain threshold, finger-to-floor distance, Roland-Morris Disability Questionnaire, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, and the Patient Global Impression of Change.
Results: At the 3-month follow-up, a large change in pain intensity (-2.2 (-2.93,-1.28), p<0.001; d=1.37) was observed for the PNE+TE group, and a moderate effect size was observed for the secondary outcome measures.
Conclusion: Combining pain neurophysiology education plus therapeutic exercise resulted in significantly better results for participants with CLBP, with a large effect size, compared to therapeutic exercise alone.
Pain neuroscience education (PNE) is an educational strategy aimed at teaching people more about pain from a neurobiological and neurophysiological perspective. Current best-evidence provides strong support for PNE to positively influence pain ratings, dysfunctions, fear-avoidance and pain catastrophization, limitations in movement, pain knowledge, and healthcare utilization. To date, all PNE studies have been conducted on adult populations. This study set out to explore if an abbreviated PNE lecture to middle school children would result in a positive shift in pain knowledge as well as healthier beliefs regarding pain. One-hundred-and-thirty-three middle school students spanning 5th to 8th grade attended a 30-minute PNE lecture. The primary outcome measures of pain knowledge (neurophysiology of pain questionnaire [NPQ]) and beliefs regarding pain (numeric rating scale) were measured before and immediately after the PNE lecture. Significant improvement in knowledge was found with mean score on NPQ test scores improving from 3.83 (29.5%) pre-PNE to 7.90 (60.8%) post-PNE (p < 0.001), with a large effect size (r = .711). Significant shifts in beliefs were also found in all but one of the pain beliefs questions, with a medium effect size for “you can control how much pain you feel” (p < 0.001; r = 0.354) and large effect size for “your brain decides if you feel pain, not your tissues” (p < 0.001; r = 0.545). This study shows that a 30-minute PNE lecture to middle school children resulted in a significant increase in their knowledge of pain as well various beliefs regarding pain.
Background:
The Tampa Scale of Kinesiophobia (TSK) is a commonly-used measure for the assessment of fear of movement beliefs in chronic complaints, but its responsiveness in subjects after lumbar fusion has been never reported.
Aim:
Evaluating the responsiveness and minimal important changes (MICs) for the TSK and its subscales after lumbar fusion.
Design:
Population-based cohort study.
Setting:
Secondary care rehabilitation hospital.
Population:
In-patients undergoing rehabilitation after lumbar fusion.
Methods:
At the beginning and end of a four-week motor and cognitive-behavioural rehabilitation program, 180 patients completed the TSK. After the intervention, the global perceived effect (GPE) was analysed to produce a dichotomous outcome (improved vs. stable). Responsiveness for the TSK and its subscales were calculated by distribution [effect size (ES); standardised response mean (SRM)] and anchor-based methods (Receiver Operating Characteristics (ROC) curves; correlations between change scores of the TSK and its subscales and GPE). ROC curves were also used to compute MIC values.
Results:
The ES ranged from 1.63 to 1.77 and the SRM from 1.25 to 1.39 for TSK and its subscales. The ROC analyses revealed a value of Area Under the Curve [95% Confidence Interval (CI)] of 0.999 [0.978; 1.000], 0.998 [0.975; 1.000], 0.990 [0.962; 0.999] for the TSK, Harm and Activity Avoidance subscales, respectively. MIC values [95% CI] greater than 6 [>5; >6], 4 [>3; >5], and 2 [>2; >2] were achieved for the TSK, Harm and Activity Avoidance subscales, respectively. Correlations between change scores of the TSK and its subscales and GPE were high (0.786-0.830).
Conclusion:
The TSK and its subscales were sensitive in detecting clinical changes in subjects undergoing rehabilitation after lumbar fusion.
Chronic musculoskeletal pain is one of the most intractable clinical problems faced by clinicians and can be devastating for patients. Central pain amplification is perceived pain that cannot be fully explained on the basis of somatic or neuropathic processes and is due to physiologic alterations in pain transmission or descending pain modulatory pathways. In any individual, central pain amplification may complicate nociceptive or neuropathic pain. Furthermore, patients with somatic symptom disorders may have alterations in their psychological or behavioral responses to pain that contribute significantly to the clinical presentation. Genetic, physiologic, and psychological factors associated with central pain amplification are beginning to be understood. One important contributor to chronic pain is perceived stress and stress response systems. We and others have shown a complex relationship between the physiologic stress response and chronic pain symptoms. Unfortunately, treatments for chronic pain are woefully inadequate and often worsen clinical outcomes. Developing new treatment strategies for patients with chronic pain is of utmost urgency. This essay provides a framework for thinking about chronic pain and developing new treatment approaches.
Even though nociceptive pathology has often long subsided, the brain of patients with chronic musculoskeletal pain has typically acquired a protective (movement-related) pain memory. Exercise therapy for patients with chronic musculoskeletal pain is often hampered by such pain memories. Here the authors explain how musculoskeletal therapists can alter pain memories in patients with chronic musculoskeletal pain, by integrating pain neuroscience education with exercise interventions. The latter includes applying graded exposure in vivo principles during exercise therapy, for targeting the brain circuitries orchestrated by the amygdala (the memory of fear centre in the brain).
Before initiating exercise therapy, a preparatory phase of intensive pain neuroscience education is required. Next, exercise therapy can address movement-related pain memories by applying the ‘exposure without danger’ principle. By addressing patients’ perceptions about exercises, therapists should try to decrease the anticipated danger (threat level) of the exercises by challenging the nature of, and reasoning behind their fears, assuring the safety of the exercises, and increasing confidence in a successful accomplishment of the exercise. This way, exercise therapy accounts for the current understanding of pain neuroscience, including the mechanisms of central sensitization.
Several questionnaires are available to evaluate illness perceptions in patients, such as the illness perception questionnaire revised (IPQ-R) and the brief version (Brief IPQ). This study aims to systematically review the literature concerning the clinimetric properties of the IPQ-R and the Brief IPQ in patients with musculoskeletal pain. The electronic databases Web of Sciences and Pubmed were searched. Studies were included when the clinimetric properties of the IPQ-R or Brief IPQ were assessed in adults with musculoskeletal pain. Methodological quality was determined using the COSMIN checklist. Eight articles were included and evaluated. The methodological quality was good for 3 COSMIN boxes, fair for 11 and poor for 3 boxes. None of the articles obtained an excellent methodological score. The results of this review suggest that the IPQ-R is a reliable questionnaire, except for illness coherence. Internal consistency is good, except for the causal domain. The IPQ-R has good construct validity, but the factor structure is unstable. Hence, the IPQ-R appears to be a useful instrument for assessing illness perceptions, but care must be taken when generalizing the results of adapted versions of the questionnaires. The Brief IPQ shows moderate overall test-retest reliability. No articles examining the validity of the Brief IPQ were found. Further research should therefore focus on the content and criterion validity of the IPQ-R and the clinimetric properties of the Brief IPQ.
Psychological factors are believed to influence the development of chronic low back pain. To date it is not known how fear avoidance beliefs influence the treatment efficacy in low back pain.
To summarize the evidence examining the influence of fear avoidance beliefs measured with the Fear Avoidance Beliefs Questionnaire (FABQ) or the Tampa Scale of Kinesiophobia (TSK) on treatment outcomes in patients with low back pain.
Systematic Review.
Patients with low back pain.
Work related outcomes and perceived measures including return to work, pain and disability METHODS: In January 2013, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, PubMed/Medline, Scopus and Web of Science. A hand search of the six most often retrieved journals and a bibliography search completed the search. Study eligibility criteria, participants, and interventions: Research studies that included patients with low back pain who participated in randomized controlled trials (RCTs) investigating non-operative treatment efficacy. Out of 646 records 78 papers were assessed in full-text and 17 RCTs were included. Study quality was high in five studies, moderate in 12 studies. This study was not funded and the authors have no conflict of interest to declare.
In patients with low back pain of up to six months duration, high fear avoidance beliefs were associated with more pain and / or disability (four RCTs) and less return to work (three RCTs) (GRADE high quality evidence, 831 patients vs. 322 in non-predictive studies). A decrease in fear avoidance beliefs values during treatment was associated with less pain and disability at follow-up (GRADE moderate evidence, two RCTs with moderate quality, 242 patients). Interventions that addressed fear avoidance beliefs were more effective than control groups based on biomedical concepts (GRADE moderate evidence, 1051 vs. 227 patients in studies without moderating effects). In chronic patients with LBP, the findings were less consistent. Two studies found baseline fear avoidance beliefs to be associated with more pain and disability and less RTW (339 patients) while three others (832 patients) found none (GRADE low evidence).
Heterogeneity of the studies impeded a pooling of the results.
Evidence suggests that fear avoidance beliefs are associated with poor treatment outcome in patients with LBP of less than six months and thus early treatment, including interventions to reduce fear avoidance beliefs, may avoid delayed recovery and chronicity. Patients with high fear avoidance beliefs are more likely to improve when fear avoidance beliefs are addressed in treatments than when these beliefs are ignored, and treatment strategies should be modified if fear avoidance beliefs are present.
To estimate the global burden of neck pain.
Neck pain was defined as pain in the neck with or without pain referred into one or both upper limbs that lasts for at least 1 day. Systematic reviews were performed of the prevalence, incidence, remission, duration and mortality risk of neck pain. Four levels of severity were identified for neck pain with and without arm pain, each with their own disability weights. A Bayesian meta-regression method was used to pool prevalence and derive missing age/sex/region/year values. The disability weights were applied to prevalence values to derive the overall disability of neck pain expressed as years lived with disability (YLDs). YLDs have the same value as disability-adjusted life years as there is no evidence of mortality associated with neck pain.
The global point prevalence of neck pain was 4.9% (95% CI 4.6 to 5.3). Disability-adjusted life years increased from 23.9 million (95% CI 16.5 to 33.1) in 1990 to 33.6 million (95% CI 23.5 to 46.5) in 2010. Out of all 291 conditions studied in the Global Burden of Disease 2010 Study, neck pain ranked 4th highest in terms of disability as measured by YLDs, and 21st in terms of overall burden.
Neck pain is a common condition that causes substantial disability. With aging global populations, further research is urgently needed to better understand the predictors and clinical course of neck pain, as well as the ways in which neck pain can be prevented and better managed.
G*Power (Erdfelder, Faul, & Buchner, 1996) was designed as a general stand-alone power analysis program for statistical tests commonly used in social and behavioral research. G*Power 3 is a major extension of, and improvement over, the previous versions. It runs on widely used computer platforms (i.e., Windows XP, Windows Vista, and Mac OS X 10.4) and covers many different statistical tests of the t, F, and chi2 test families. In addition, it includes power analyses for z tests and some exact tests. G*Power 3 provides improved effect size calculators and graphic options, supports both distribution-based and design-based input modes, and offers all types of power analyses in which users might be interested. Like its predecessors, G*Power 3 is free.
Within a biopsychosocial framework, psychological factors are thought to play an important role in the onset and progression of chronic pain. The cognitive-behavioral fear-avoidance model of chronic pain suggests that pain-related fear contributes to the development and maintenance of pain-related disability. However, investigations of the relation between pain-related fear and disability have demonstrated considerable between-study variation. The main goal of the current meta-analysis was to synthesize findings of studies investigating cross-sectional associations between pain-related fear and disability in order to estimate the magnitude of this relation. We also tested potential moderators, including type of measure used, demographic characteristics, and relevant pain characteristics. Searches in PubMed and PsycINFO yielded a total of 46 independent samples (N = 9,579) that reported correlations between pain-related fear and disability among persons experiencing acute or chronic pain. Effect size estimates were generated using a random-effects model and artifact distribution method. The positive relation between pain-related fear and disability was observed to be moderate to large in magnitude, and stable across demographic and pain characteristics. Although some variability was observed across pain-related fear measures, results were largely consistent with the fear-avoidance model of chronic pain.
Results of this meta-analysis indicate a robust, positive association between pain-related fear and disability, which can be classified as moderate to large in magnitude. Consistent with the fear-avoidance model of chronic pain, these findings suggest that pain-related fear may be an important target for treatments intended to reduce pain-related disability.
Study design:
A cross-sectional study design was performed.
Objective:
To validate the pain disability index (PDI) extensively in 3 groups of patients with musculoskeletal pain.
Summary of background data:
The PDI is a widely used and studied instrument for disability related to various pain syndromes, although there is conflicting evidence concerning factor structure, test-retest reliability, and missing items. Additionally, an official translation of the Dutch language version has never been performed.
Methods:
For reliability, internal consistency, factor structure, test-retest reliability and measurement error were calculated. Validity was tested with hypothesized correlations with pain intensity, kinesiophobia, Rand-36 subscales, Depression, Roland-Morris Disability Questionnaire, Quality of Life, and Work Status. Structural validity was tested with independent backward translation and approval from the original authors.
Results:
One hundred seventy-eight patients with acute back pain, 425 patients with chronic low back pain and 365 with widespread pain were included. Internal consistency of the PDI was good. One factor was identified with factor analyses. Test-retest reliability was good for the PDI (intraclass correlation coefficient, 0.76). Standard error of measurement was 6.5 points and smallest detectable change was 17.9 points. Little correlations between the PDI were observed with kinesiophobia and depression, fair correlations with pain intensity, work status, and vitality and moderate correlations with the Rand-36 subscales and the Roland-Morris Disability Questionnaire.
Conclusion:
The PDI-Dutch language version is internally consistent as a 1-factor structure, and test-retest reliable. Missing items seem high in sexual and professional items. Using the PDI as a 2-factor questionnaire has no additional value and is unreliable.
Objectives:
There is evidence that education on pain physiology can have positive effects on pain, disability, and catastrophization in patients with chronic musculoskeletal pain disorders. A double-blind randomized controlled trial (RCT) was performed to examine whether intensive pain physiology education is also effective in fibromyalgia (FM) patients, and whether it is able to influence the impaired endogenous pain inhibition of these patients.
Methods:
Thirty FM patients were randomly allocated to either the experimental (receiving pain physiology education) or the control group (receiving pacing self-management education). The primary outcome was the efficacy of the pain inhibitory mechanisms, which was evaluated by spatially accumulating thermal nociceptive stimuli. Secondary outcome measures included pressure pain threshold measurements and questionnaires assessing pain cognitions, behavior, and health status. Assessments were performed at baseline, 2 weeks, and 3 months follow-up. Repeated measures ANOVAS were used to reveal possible therapy effects and effect sizes were calculated.
Results:
After the intervention the experimental group had improved knowledge of pain neurophysiology (P<0.001). Patients from this group worried less about their pain in the short term (P=0.004). Long-term improvements in physical functioning (P=0.046), vitality (P=0.047), mental health (P<0.001), and general health perceptions (P<0.001) were observed. In addition, the intervention group reported lower pain scores and showed improved endogenous pain inhibition (P=0.041) compared with the control group.
Discussion:
These results suggest that FM patients are able to understand and remember the complex material about pain physiology. Pain physiology education seems to be a useful component in the treatment of FM patients as it improves health status and endogenous pain inhibition in the long term.
We examine the correlations between the national IQs of Lynn and Vanhanen (Lynn, R. and Vanhanen, T. (2002). IQ and the wealth of nations. Westport, CT: Praeger. Westport, CT: Praeger, Lynn, R. and Vanhanen, T. (2006). IQ and global inequality. Athens, GA: Washington Summit Books.) and educational attainment scores in math and science for 10- and 14-year olds in 25 countries and 46 countries (respectively) given in the TIMSS 2003 reports. It was found that national IQs had (attenuation corrected) correlations of between 0.92 and 1.00 with scores in math and science. The results are interpreted as a validation of the national IQs. They suggest that national differences in educational attainment may be attributable to differences in IQ, or alternatively that national IQs and in educational attainment are both indicators of the mental ability of national populations. It is also shown that national IQs are positively associated with national per capita income (r = .61). It is proposed that these have a reciprocal positive feedback relationship such that each augments the other.
Exercise and education is a common physiotherapy approach in the prevention of low back pain. A Mensendieck exercise programme consisting of exercises and ergonomical education has, in a previous study, been shown to be effective in preventing recurrent low back pain during one-year follow-up. The purpose of the present study was to evaluate the long-term effect of the Mensendieck exercise programme on people with recurrent episodes of low back pain who, when entering the study, had finished treatment for their last episode of low back pain.
A randomized controlled clinical trial in which 41 women and 36 men were allocated to either a Mensendieck or control group. The Mensendieck subjects received 20 group sessions of exercises and ergonomical education over 13 weeks. The control subjects were not offered any prophylactic therapy, but were free to receive treatment or exercises. Outcome measures were the number of recurrences of low back pain, sick leave, low back function and general functional status.
At three-year follow-up, 11 subjects had been lost to the study. Survival analysis showed a significant reduction (p=0.02) in subjects experiencing recurrent low back pain in the Mensendieck group compared to the control group. Significant improvements in pain and function scores were reported in both groups. There was no significant difference between the groups in pain, function or sick leave.
A Mensendieck exercise programme seems efficient in reducing recurrent episodes of low back pain at three-year follow-up, but it did not influence sick leave, pain or function scores. Copyright
Systematic review.
To identify, describe, and evaluate common outcome measures in patients with chronic low back pain (CLBP).
The treatment of CLBP has been associated with multiple clinical challenges. Further complicating this is the myriad of outcome scores used to assess treatment of CLBP. These scores have been used to examine different domains of patient satisfaction and quality of life in the literature. Critical assessment of the frequency, parity, and the quality of these outcomes are essential to improve our understanding of CLBP.
A systematic review of the English-language literature was undertaken for articles published from January 2001 through December 31, 2010. Electronic databases and reference lists of key articles were searched to identify measures used to evaluate outcomes in six different domains in patients with CLBP. The titles and abstracts of the peer-reviewed literature of LBP were searched to determine which of these measures were most commonly reported in the literature and which have been validated in populations with CLBP.
We identified 75 outcome measures cited to evaluate CLBP. Twenty-nine of these outcome measures were excluded because of only a single citation leaving 46 measures for the evaluation. The most commonly used functional outcomes were the Oswestry Disability Index, Roland Morris Disability Index, and range of motion. For pain, the Numeric Pain Rating Scale, Brief Pain Inventory, Pain Disability Index, McGill Pain Questionnaire, and visual analog scale were most commonly cited. For psychosocial function, the Fear Avoidance Beliefs Questionnaire, Tampa Scale for Kinesiophobia, and Beck Depression Inventory were most commonly used. For generic quality of life, short form 36, Nottingham Health Profile, short form 12, and Sickness Impact Profile were the most common measures. For objective measures, the work status/return to work, complications or adverse events, and medications used were the most commonly cited. For preference-based measures, the Euro-Quol 5 dimensions and short form 6 dimensions were most commonly cited. The validity, reliability, responsiveness, universality, and potential proprietary requirements are summarized for each.
Outcome measures should be routinely assessed in patients with CLBP. The choice of appropriate outcome measure should be influenced by the study objectives and design, as well as properties of the particular measure within the context of CLBP.
Recommendation 1: When selecting the appropriate outcome measures for clinical or research purposes, consider domains that best measure what are most important to patients. Measures that are valid, reliable, and responsive to change should be considered first. Other considerations include the number of items required (especially in the context of multiple measures), whether the measure is validated in the relevant language, and the associated costs or fees. Strength: Strong Recommendation 2: Domains of greatest importance include pain, function, and quality of life. If cost utilization is a priority, then preference-based measures should be considered. For pain, we recommend the VAS and NRPS because of their ease of administration and responsiveness. For function, we recommend the ODI and RMDQ. The SF-36 and its shorter versions are most commonly used and should be considered if quality of life is important. If cost utility is important, consider the EQ-5D or SF-6D. Psychosocial tests are best used as screening tools prior to surgery because of their lack of responsiveness. Complications should always be assessed as a standard of clinical practice. Return to work and medication use are complicated outcome measures and not recommended unless the specific study question is focused on these domains. Consider staff and patient burden when prioritizing one's battery of measures.
To perform a systematic review of the global prevalence of low back pain, and to examine the influence that case definition, prevalence period, and other variables have on prevalence.
We conducted a new systematic review of the global prevalence of low back pain that included general population studies published between 1980 and 2009. A total of 165 studies from 54 countries were identified. Of these, 64% had been published since the last comparable review.
Low back pain was shown to be a major problem throughout the world, with the highest prevalence among female individuals and those aged 40-80 years. After adjusting for methodologic variation, the mean ± SEM point prevalence was estimated to be 11.9 ± 2.0%, and the 1-month prevalence was estimated to be 23.2 ± 2.9%.
As the population ages, the global number of individuals with low back pain is likely to increase substantially over the coming decades. Investigators are encouraged to adopt recent recommendations for a standard definition of low back pain and to consult a recently developed tool for assessing the risk of bias of prevalence studies.
Non-specific low back pain has become a major public health problem worldwide. The lifetime prevalence of low back pain is reported to be as high as 84%, and the prevalence of chronic low back pain is about 23%, with 11-12% of the population being disabled by low back pain. Mechanical factors, such as lifting and carrying, probably do not have a major pathogenic role, but genetic constitution is important. History taking and clinical examination are included in most diagnostic guidelines, but the use of clinical imaging for diagnosis should be restricted. The mechanism of action of many treatments is unclear, and effect sizes of most treatments are low. Both patient preferences and clinical evidence should be taken into account for pain management, but generally self-management, with appropriate support, is recommended and surgery and overtreatment should be avoided.
Prospective cohort study.
The objective of this study was to test the responsiveness and minimal clinically important change (MCIC) of the Pain Disability Index (PDI) in patients with chronic back pain (CBP).
Treatment of patients with CBP is primarily focused on reduction of disability. For disability measurement, the PDI is a widely used questionnaire. There are, however, no data available on responsiveness and MCIC.
Two hundred forty-two patients with CBP were included in this study. Patients filled in the PDI at baseline and at discharge. The PDI consists of 2 subscales: 1 measuring voluntary activities and 1 measuring obligatory activities. PDI was anchored at 2 self-reported global perceived effect (GPE) scales for complaints and self-care, respectively. Responsiveness was considered sufficient when Area Under the Receiver Operating Characteristics (ROC) Curve (AUC) was higher than 0.70. To test interpretability, change scores and MCIC were calculated. MCIC was tested by determination of optimal cut-off point of the ROC curve and determination of specificity and sensitivity of the optimal cut-off point.
AUCs were 0.76 and 0.77 depending on the external criterion. The subscale obligatory activities did not meet the criteria for responsiveness (AUC: 0.63-0.69). MCIC of the PDI was 9.5 points for GPE "complaints" and 8.5 for GPE "self-care."
The total score of the PDI as well as the subscale of voluntary activities is responsive. Partly because of floor effects, the subscale obligatory activities are not sufficiently responsive in patients with CBP. However, the responsiveness of this subscale in other patient groups should be further tested. In patients with CBP, change can be considered clinically important when PDI score has decreased 8.5 to 9.5 points.