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Theefficacyofpainneuroscienceeducationonmusculoskeletalpain:Asystematicreviewoftheliterature

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DOI:10.1080/09593985.2016.1194646

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The efficacy of pain neuroscience education on musculoskeletal pain:A systematic review of the literatureAdriaan Louw, PT, PhDa, Kory Zimney, PT, DPTb, Emilio J. Puentedura, PT, DPT, PhDc, and Ina Diener, PT, PhDd

aInternational Spine and Pain Institute, Story City, IA, USA; bDepartment of Physical Therapy, School of Health Sciences, University of SouthDakota, Vermillion, SD, USA; cDepartment of Physical Therapy, School of Allied Health Sciences, University of Nevada, Las Vegas, Las Vegas,NV, USA; dDepartment of Physiotherapy, Stellenbosch University, Stellenbosch, South Africa

ABSTRACTObjective: Systematic review of randomized control trials (RCTs) for the effectiveness of painneuroscience education (PNE) on pain, function, disability, psychosocial factors, movement, and health-care utilization in individuals with chronic musculoskeletal (MSK) pain. Data Sources: Systematicsearches were conducted on 11 databases. Secondary searching (PEARLing) was undertaken, wherebyreference lists of the selected articles were reviewed for additional references not identified in theprimary search. Study Selection: All experimental RCTs evaluating the effect of PNE on chronicMSK painwere considered for inclusion. Additional Limitations: Studies published in English, published withinthe last 20 years, and patients older than 18 years. No limitationswere set on specific outcomemeasures.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 by2 reviewers using the PEDro scale. Narrative summary of results is provided for each study in relation tooutcomes measurements and effectiveness. Conclusions: Current evidence supports the use of PNEfor chronic MSK disorders in reducing pain and improving patient knowledge of pain, improvingfunction and lowering disability, reducing psychosocial factors, enhancing movement, and minimizinghealthcare utilization.

ARTICLE HISTORYReceived 12 November 2015Revised 19 December 2015Accepted 26 January 2016

KEYWORDSChronic pain; explain pain;pain neuroscienceeducation; therapeuticneuroscience education

Introduction

Pain is a normal human experience and the inability toexperience pain provides a significant risk to survivalfor any human being (Gifford, 2014; Moseley, 2003a;Moseley, 2007). Living in pain though is not a normalhuman experience and a powerful motivating force toseek help (Bernard and Wright, 2004; Louw, Louw, andCrous, 2009; Mortimer et al., 2003). One treatmentstrategy aimed at helping ease pain and often theassociated suffering and disability is patient education(Brox et al., 2008; Engers et al., 2008; Heymans et al.,2005; Liddle, Gracey, and Baxter, 2007). Traditionalmusculoskeletal (MSK) education models have focusedheavily on biomedical education focusing on anatomy,biomechanics, and pathoanatomy (Brox et al., 2008;Maier-Riehle and Härter, 2001; Moseley, 2003a, 2004).In these educational models clinicians aim to explain apain experience to patients from a tissue perspective, beit contrasting healthy (anatomy) and injured tissues(pathoanatomy) or highlighting a mechanical deviancefrom normal expected patterns of movement (biome-chanics) or a disease state such as degenerative changes(pathoanatomy) (Haldeman, 1990; Louw and Butler,

2011). Although these models may have clinical valuein more acute phases of injury, surgical, or diseasestates, they lack the ability to explain complex issuesassociated with pain, including peripheral and centralsensitization, facilitation and inhibition, neuroplasticity,immune and endocrine changes, and more, all of whichhave been implicated in more complex and persistentpain states (Gifford, 2014; Moseley, 2003a; Nijs et al.,2013; Woolf, 2007). Furthermore, these biomedicaleducational models have not only shown limited effi-cacy in alleviating pain and disability (Brox et al., 2008;Koes, van Tulder, van der Windt, and Bouter, 1994;Maier-Riehle and Härter, 2001; Waddell, 2004) but mayeven increase patient fears, anxiety, and stress, thusnegatively impacted their intended outcomes (Hirschand Liebert, 1998; Maier-Riehle and Härter, 2001;Nachemson, 1992; Poiraudeau et al., 2006).

In lieu of the limited efficacy of traditional education toalleviate pain and disability, especially in persistent pain, anew model was needed and proposed (Butler andMoseley, 2003; Gifford, 1998; Gifford, 2014; Gifford andButler, 1997; Gifford and Muncey, 1999; Moseley andButler, 2015). People in pain are interested in learning

CONTACT Adriaan Louw, PT, PhD adriaan@ispinstitute.com International Spine and Pain Institute, P.O. Box 232, Story City, IA 50248, USA.

PHYSIOTHERAPY THEORY AND PRACTICEhttp://dx.doi.org/10.1080/09593985.2016.1194646

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more about their pain (Louw, Louw, and Crous, 2009;Louw, Diener, Butler, and Puentedura, 2013; Moseley,2003b; Rönnberg et al., 2007). This educational model ofteaching people about pain biology and physiology iscalled therapeutic neuroscience education (Louw,Puentedura, Diener, and Peoples 2015; Zimney, Louw,and Puentedura, 2014), explain pain (Butler andMoseley, 2003; Moseley and Butler, 2015), and pain neu-roscience education (PNE) (Nijs et al., 2011, 2013). PNEaims to explain to patients the biological and physiologi-cal processes involved in a pain experience and, moreimportantly, defocus the issues associated with the anato-mical structures (Louw, Diener, Butler, and Puentedura,2011; Moseley, 2007; Moseley, Nicholas, and Hodges,2004; Nijs et al., 2011, 2013). Following early calls forthe further study and clinical application of PNE(Gifford, 1998; Gifford and Butler, 1997) and the firstconference presentation of explaining pain to patients(Gifford and Muncey, 1999), scientists used an evi-dence-based platform to further investigate PNE.Subsequently, various randomized controlled trials(RCT) and two systematic reviews explored the efficacyof PNE (Clarke, Ryan, and Martin, 2011; Louw, Diener,Butler, and Puentedura, 2011; Meeus et al., 2010; Moseley,2002; Moseley, Nicholas, and Hodges, 2004; Ryan, Gray,Newton, and Granat, 2010). At the end of 2011, thesystematic review of Louw, Diener, Butler, andPuentedura (2011) demonstrated for MSK pain, TNEprovides compelling evidence in reducing pain, disability,pain catastrophization, and limited physical movement.

The review by Louw, Diener, Butler, and Puentedura(2011) included eight studies (Meeus et al., 2010;Moseley, 2002, 2003b, 2003c, 2004; Moseley, Nicholas,and Hodges, 2004; Ryan, Gray, Newton, and Granat,2010; Van Oosterwijck et al., 2011), ranging in datefrom 2002 (Moseley, 2002) to 2011 (Van Oosterwijcket al., 2011). Since the publication of the last systematicreview, various studies utilizing PNE have been pub-lished (Gallagher, McAuley, and Moseley, 2013;Ittersum et al., 2014; Louw, Diener, Landers, andPuentedura, 2014; Robinson and King, 2011; VanIttersum, van Wilgen, Groothoff, and Van der Schans,2011). This growth of additional PNE studies, alongwith the reflection by Moseley and Butler (2015) on15 years of teaching people about pain begs the ques-tion if the increased research activity in PNE hasresulted in any increased evidence for this educationalapproach? The original review was also handicapped inassessing efficacy by including lower level papers andthe inability to evaluate methodologically each study incomparative fashion. The goal of this systematic reviewis to update and explore the efficacy of PNE as atreatment approach for people suffering MSK pain.

Methods

In line with the goal of the updated systematic review,the authors used the same methodology reported byLouw, Diener, Butler, and Puentedura (2011) as ameans to add to and thus combine the cumulativeevidence for PNE. The end result would be an expan-sion of the research results ranging from 2002(Moseley, 2002) to the present. Additionally, the newreview only included RCTs.

Search strategy

An electronic search was performed between June 2015and August 2015, covering the last 14 years (2002–2015)from the following databases: Biomed Central, BMJ.com,CINAHL, the Cochrane Library, NLM Central Gateway,OVID, ProQuest (Digital Dissertations), PsycInfo,PubMed/Medline, ScienceDirect, and Web of Science.Each database has its own indexing terms and functions,and therefore different search strategies were developedfor each database by the authors. The main searchitems were education, neuroscience, neurobiology, neu-rophysiology, pain, pain education, pain science, andtherapeutic. In PubMed, medical subject headings(MeSH) terms were used where possible, with Booleanoperators. The search strategies for remaining databasesincluded synonyms of the main search items. Secondarysearching (PEARLing) was undertaken, whereby refer-ence lists of the selected articles were reviewed foradditional references not identified in the primary search.The titles and abstracts of all the identified literature werescreened by one primary reviewer using the inclusioncriteria below. The full text of all potentially relevantarticles were retrieved and screened by two reviewersusing the same criteria, in order to determine theeligibility of the paper for inclusion in the review.

Inclusion criteria

All titles and abstracts were read to identify relevantpapers. Papers were included in this systematic reviewif they met the inclusion criteria listed in Table 1. Giventhe heterogeneous nature of the original systematicreview’s outcome measures, no parameters were seton the exact measurement tools used to assess the effectof PNE on patients suffering from MSK pain. Whenthere was uncertainty regarding the eligibility of thepaper from the abstract, the full text version of thepaper was retrieved and evaluated against the inclusioncriteria. The full text version of all papers that met theinclusion criteria were retrieved for quality assessmentand data extraction.

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Quality assessment

Critical appraisal of each included study was conductedby determining the level of evidence on the AustralianNational Health and Medical Research Council(NHMRC) Hierarchy of Evidence (National Healthand Medical Research Council, 1999). This provides abroad indication of bias based on study design. Studieshigher on the hierarchy potentially contain less biasthan those that are lower on the hierarchy. Given theincreased activity in the field of PNE, study designsother than RCT were excluded in this review becauseof the lower level of evidence they provide.

Methodological quality of the design and reporting ofeach study was assessed against the PEDro scale (Elkinset al., 2010). The PEDro scale has become widely used torate physical therapy interventions and has been shownto have reliability and a valid measure of methodologicalquality of clinical trials (de Morton, 2009; Maher et al.,2003). A high-quality study was defined by the authorsas scoring positive on a minimum of 50% (5/10) ofthe items. Each reviewer conducted an independentevaluation and PEDro scoring of the studies in thereview. The Physiotherapy Evidence Database wascross-referenced for any article already having aconfirmed review, and the confirm score was used ifpresent. If differences were found between reviewers,a discussion was held to attempt consensus. Any differ-ences that could not be agreed upon were to be evaluatedby a third reviewer (E. J. Puentedura) to come to a finaljudgement among all reviewers. No disagreements inPEDro scoring occurred during assessment of thearticles.

Outcome assessment

Due to the heterogeneous nature of the original systema-tic review’s outcome measures and to determine thepossible influence of PNE for MSK pain, results wereposted in narrative form and outcomes were defined as“positive” (experimental group obtained a significantlygreater improvement than the control group); “neutral”(there were no statistically significant differences

between the groups); or “negative” (the control groupobtained a significant greater improvement than theexperimental group). An alpha of p < 0.05 was used todefine a significant outcome measure. This method, usedin previous systematic reviews, demonstrated four levelsof scientific evidence on the quality and the outcome ofthe trials: (1) strong evidence: multiple, relevant, high-quality RCTs with generally consistent outcomes;(2) moderate evidence: one relevant, high-quality RCTAND one or more relevant, low-quality RCTs with gen-erally consistent outcomes; (3) limited evidence: onerelevant, high-quality RCT OR multiple relevant low-quality RCTs with generally consistent outcomes; and(4) inconclusive evidence: only one relevant, low-qualityRCT, no relevant RCTs or randomized trials withinconsistent outcomes (Ezzo et al., 2000; Fernández-de-las-Peñas et al., 2006).

A study was considered “relevant” when at least oneof the outcome measures concerned pain or disability.For being “generally consistent,” at least 75% of thetrials that analyzed the same PNE had to have thesame result (positive, neutral, or negative).

Data extraction

Data were extracted by the authors using the PICOapproach: Participants: diagnosis treated, age, sex, dura-tion of the symptoms, type of referral source,and diagnostic criteria; Interventions: type, intensity,duration, educational tools/props, in combination orstand-alone physical therapy; Comparison: to anothertreatment, no treatment, or “usual” treatment; andOutcomes: domains and tools used to measure the effectsof the intervention. Although outcomes were not speci-fied or limited, primary outcomes in line with “relevance”stated above included pain and/or function (Stone, 2002).

Data on the effectiveness of the PNE were alsoextracted for each study. To determine the effect ofthe PNE on each outcome measure, the mean and95% confidence intervals (CI) for the between-groupdifferences were calculated for RCTs and comparativestudies, based on the results provided in each article

Table 1. Inclusion criteria used in the systematic review.Criterion Justification

English language Search reviewers’ primary language is English, and major journals in the subject area are published inEnglish.

1999–2015 First study found was published in 2002.Humans older than 18 years Increase homogeneity of participants between studies as educational needs for infants, children, and

adolescents.MSK pain Increase homogeneity of participants being treated with educational strategies incorporating PNE.RCTs Utilization of Level 1 evidence according to Centre for Evidence-based Medicine.PNE Increase homogeneity on type of educational intervention.Outcomes: pain, function, psychosocial factors,movement, healthcare utilization

These are primary outcome measurements performed in the literature regarding individuals withMSK pain. No limitation was set on specific measurement tools utilized to examine effect onoutcomes in these areas.

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(Herbert, 2000). Moreover, the mean changes betweenpre- and post-treatment (and 95% CI) were calculatedfor the RCTs. Pain reduction of more than 20%, irre-spective of the measurement tool used, was consideredclinically worthwhile (Farrar et al., 2001; Ferreira et al.,2002). It was expected that there would be heterogene-ity in participants, interventions, comparisons, andoutcomes. Therefore, the results of the studies weresynthesized in a narrative format.

Results

Search strategy yield

Initially, therewere 25,911hits gathered fromdatabases andsecondary searches for the search dates defined in themethods. After reviewing titles and abstracts, articlesnot meeting inclusion criteria were removed. Full textreview left 99 eligible articles, after removal ofduplicates there were 8 studies from the updated review

Table 2. Assessment of the quality of the randomized trials (n = 13) using the PEDro scale.Criteria 1 2 3 4 5 6 7 8 9 10 11 Total

Moseley (2002) Y Y Y Y N N Y Y Y Y Y 8/10Moseley (2003c) Y Y Y Y N N Y Y N Y Y 7/10Moseley et al. (2004) Y Y Y Y Y Y Y Y N Y Y 9/10Ryan et al. (2010) Y Y Y Y N Y Y Y N Y Y 8/10Meeus et al. (2010) Y Y Y Y Y N Y Y Y Y Y 9/10Vibe Fersum et al. (2013) Y Y Y Y Y N Y N N Y Y 7/10Gallagher et al. (2013) Y Y Y Y Y Y Y Y Y Y Y 10/10Van Oosterwijck et al. (2013) Y Y Y Y Y N Y Y Y Y Y 9/10Ittersum et al. (2014) Y Y Y Y N N Y N Y Y Y 7/10Louw et al. (2014) Y Y Y Y Y N Y Y Y Y Y 9/10Téllez-García et al. (2014) Y Y Y Y N N Y Y Y Y Y 8/10Beltran-Alacreu et al. (2015) Y Y Y Y N N Y Y Y Y Y 8/10Pires et al. (2015) Y Y Y Y N sN Y Y Y Y Y 8/10

Figure 1. Retrieval and review process.

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along with 5 eligible studies from previous review. Thissystematic review is based on these 13 published RCTs(Figure 1) (Beltran-Alacreu, Lopez-de-Uralde-Villanueva,Fernandez-Carnero, and La Touche, 2015; Gallagher,McAuley, and Moseley, 2013; Ittersum et al., 2014; Louw,Diener, Landers, and Puentedura, 2014; Meeus et al., 2010;Moseley, 2002, 2003c; Moseley, Nicholas, and Hodges,2004; Pires, Cruz, and Caeiro, 2015; Ryan, Gray, Newton,and Granat, 2010; Téllez-García et al., 2014; VanOosterwijck et al., 2013; Vibe Fersum et al., 2013). The13 RCTs comprised 734 patients.

Critical appraisal

Hierarchy of evidenceAll 13 published papers were RCTs.

Methodological qualityThe papers were reviewed against the PEDro scale.Agreement was obtained between reviewers and com-pared with the PEDro Database on each of the cri-teria in the PEDro scale with results listed in Table 2.All the studies scored a 6/10 or higher on the PEDroscale demonstrating good methodological quality.The blinding of subjects and those that administeredthe therapy were the most common criteria not met.This is partially due to the face-to-face delivery styleof the intervention of PNE making it difficult toblind the person providing and receiving the PNE.

Educational content and delivery methods

Naming the interventionThe original systematic review (Louw, Diener, Butler,and Puentedura, 2011) reported on the variousnames given to the educational intervention ofexplaining the biology of the pain experience to thepatient with the aim at reducing pain and disability.The continued variation in the interventional nameused by the various authors continues: (1) pain neu-rophysiology education (Pires, Cruz, and Caeiro,2015); (2) therapeutic patient education (Beltran-Alacreu, Lopez-de-Uralde-Villanueva, Fernandez-Carnero, and La Touche, 2015); (3) neuroscienceeducation (Téllez-García et al., 2014); (4) painphysiology education (Meeus et al., 2010; Moseley,2003c; Van Oosterwijck et al, 2013); (5) Pain neu-roscience education (Ittersum et al, 2014; Louw,Diener, Landers, and Puentedura, 2014); (6) neuro-physiology education (Moseley, Nicholas, andHodges, 2004); (7) pain biology education (Ryan,Gray, Newton, and Granat, 2010); and (8) neurophy-siology of pain education (Moseley, 2002).

Two studies did not directly call the educationalintervention a specific name but were a part of a bookof metaphors and stories to help understand thebiology of pain (Gallagher, McAuley, and Moseley,2013) and the cognitive component of the educationintervention (Vibe Fersum et al., 2013).

Patient characteristicsThere were 734 subjects in the reviewed manuscriptswith 398 of them receiving PNE (70% female). Themean age of subjects receiving educational interventionwas 41.7 years (calculated from the means of the meanreported ages from each study). The youngest cohorthad a mean age of 24 ± 10 years (Moseley, Nicholas,and Hodges, 2004) and the oldest cohort had 50.9 ± 6.2years (Pires, Cruz, and Caeiro, 2015). PNE was utilizedfor multiple pain conditions: low back pain, chronicfatigue syndrome, fibromyalgia, lumbar radiculopathyawaiting lumbar surgery, and chronic neck pain.

Content of therapeutic neuroscience educationSpecific content of each of the educational sessions canbe found in Table 3. Summary of the PNE content were

● Neurophysiology of pain (Beltran-Alacreu, Lopez-de-Uralde-Villanueva, Fernandez-Carnero, and LaTouche, 2015; Gallagher, McAuley, and Moseley,2013; Ittersum et al., 2014; Louw, Diener, Landers,and Puentedura, 2014; Meeus et al., 2010;Moseley, 2002, 2003c; Moseley, Nicholas, andHodges, 2004; Pires, Cruz, and Caeiro, 2015;Ryan, Gray, Newton, and Granat, 2010; VanOosterwijck et al., 2013; Vibe Fersum et al., 2013)

● No reference of anatomic or patho-anatomicmodels (Moseley, 2002, 2003c; Moseley, Nicholas,and Hodges, 2004; Téllez-García et al., 2014)

● No discussion of the emotional or behavioralaspects of pain (Moseley, 2003c; Moseley,Nicholas, and Hodges, 2004)

● Nociception and nociceptive pathways (Gallagher,McAuley, and Moseley, 2013; Ittersum et al., 2014;Louw, Diener, Landers, and Puentedura, 2014;Moseley, 2003c; Moseley, Nicholas, and Hodges,2004; Pires, Cruz, and Caeiro, 2015; Téllez-Garcíaet al., 2014)

● Synapses (Moseley, 2003c; Moseley, Nicholas, andHodges, 2004)

● Action potentials (Louw, Diener, Landers, andPuentedura, 2014)

● Spinal inhibition and facilitation (Gallagher,McAuley, and Moseley, 2013; Moseley, 2003c;Van Oosterwijck et al., 2013; Vibe Fersum et al.,2013)

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Table3.

Participants,interventions,and

outcom

esin

thereview

edstud

ies.

Participants

Interventio

nsOutcomes

Author

nSample

characteristics

Diagn

ostic

criteria

Treatm

ent

Control

Outcome

instruments

Timeof

assessment

Moseley

(2002)

57●

LBP>2

mon

ths

●Wom

en=

59%

●Ag

e(years):

EG*43

±7

andCG

**38

±7 Durationof

symptom

s(m

onths):EG

=39

±18

and

CG37

±12

NA

Twoph

ysiotherapysessions

perweekfor4

weeks;m

anualtherapy

includ

ingmob

ilizatio

nandmanipulation,softtissuemassage,m

uscle

andneural-m

obilizatio

ntechniqu

es,b

utno

electrop

hysicalm

odalities;specific

trun

kstabilizatio

nprog

ram;m

aintainho

me

exercisesindefin

itely;1

hour

educational

sessionon

ceaweekfor4weeks;o

ne-on-on

eeducationform

atby

anindepend

ent

therapist;content=neurop

hysiolog

yof

pain

with

noreferenceto

lumbarspine;

accompanied

byworkbookwith

onepage

ofrevision

materiala

ndthreecomprehensive

exercisesperdayfor10

days

Ong

oing

medicalcare

asadvisedby

their

generalp

ractition

er.

Noattend

ance

ofph

ysiotherapy

●Num

ericratin

gscale(NRS);

meaning

fuld

if-ferencesetat

2po

ints

●Roland

Morris

Disability

Questionn

aire

(RMDQ);mean-

ingful

diffe

rence

setat

4po

ints

●Num

bers

needed

totreat(NNT)

Baseline,1mon

thafter

interventio

nand1year

afterinterventio

n

Moseley

(2003c)

41●

LBP>3

mon

ths

●Wom

en=EG

67%

andCG

=60%

●Ag

e(years):

EG=40

±7

yearsandCG

=42

±7years

Durationof

symptom

s(m

onths):EG

=33

±11

and

CG=30

±14

NA

Individu

al4×1ho

ureducationalsession

ontheph

ysiology

ofpain

andinjury

bya

physiotherapist;additio

nally

received

two

physiotherapysessions

perweekfor4weeks

focusing

onspinalstabilizatio

nexercises

Group

sessioninvolved

asing

le4-ho

ursession

with

agrou

pof

7–10

patientsprovided

bya

physiotherapist;ph

ysiology

ofpain

andinjury;

additio

nally

received

twoph

ysiotherapy

sessions

perweekfor4weeks

focusing

onspinalstabilizatio

nexercises

●Num

ericratin

gscale(NRS)

●Roland

Morris

Disability

Questionn

aire

(RMDQ)

●Num

bers

needed

totreat(NNT)

Baseline,1mon

thfollowing“ong

oing

medicaltreatm

ent”and1

mon

thand2mon

thsafter

educationaland

physiotherapysessions

(Con

tinued)

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Table3.

(Con

tinued).

Participants

Interventio

nsOutcomes

Author

nSample

characteristics

Diagn

ostic

criteria

Treatm

ent

Control

Outcome

instruments

Timeof

assessment

Moseley

etal.(2004)

58●

LBP>6

mon

ths

●Ag

e(years):

EG=24

±10

andCG

=45

±6

●Durationof

pain

(mon

ths):

EG=18

±11

andCG

=20

±11

NA

Educationsessionby

aph

ysiotherapistinon

e-to-one

seminar

form

at;session

lasted

3ho

urs;

diagramsandhypo

thetical

exam

ples

used

asteaching

tools;at

conclusion

:workbookwith

10sections;p

atientsaskedto

read

one

sectionperdayandansw

erthreequ

estio

nson

each

session

Neurophysiology

Education

Nospecificapplicationwas

madeto

thelower

back,o

rto

emotionaland

behavioralpatterns

common

lyassociated

with

chronicpain

such

ascatastroph

icthou

ghtprocessesor

fear

avoidance

TheNervousSystem

Presentatio

nof

thebasicstructureof

the

nervou

ssystem

,with

afocuson

the

compo

nentsof

theno

ciception/pain

pathways;thissectioninclud

edan

outline

ofthefunctio

nalsignificance

ofeach

compo

nent

Synapses

Presentatio

nof

how

nerves

“talkto

each

other,”

includ

ingtheconceptof

“chemicals”

(neurotransm

itters),p

ostsynaptic

receptors,

andaconceptual“volum

eknob

”(postsynaptic

excitatio

nandinhibitio

n),w

itha

specialfocus

onthe“dangermesseng

ernerve”

(secon

dorderno

ciceptiveneuron

)Plasticity

oftheNervousSystem

Theadaptabilityof

thenervou

ssystem

includ

ing:

afferent

andefferent

pathways;the

variablestateof

neuralstructures

includ

ing

norm

alstate,perip

heral,andcentral

sensitizatio

n;receptor

synthesis;axon

alsprouting;

theneuralrespon

seto

inactivity;

andmovem

entcontrol

Educationsessionby

aph

ysiotherapistinon

e-to-one

seminar

form

at;session

lasted

3ho

urs;

diagramsandhypo

theticalexam

ples

used

asteaching

tools;at

conclusion

:workbookwith

10sections;p

atientsaskedto

read

one

sectionperdayandansw

erthreequ

estio

nson

each

session

BackEducation

Anatom

yandph

ysiology

ofthebo

nesand

jointsof

thelumbarspine;theintervertebral

disc;the

trun

kandback

muscles;n

ormal

spinalcurves;p

osture

andmovem

ents,

includ

inganalysisof

postures

andactivities

accordingto

intra-discalpressuresandjoint

forces;liftingtechniqu

esandliftin

gloads;

liftin

gaids

andergo

nomicsadvice;p

rinciples

ofstretching

;and

streng

th,end

urance,and

fitness

training

Itdidno

tinclud

einform

ationabou

tthe

nervou

ssystem

,exceptforou

tlining

the

locatio

nandcourse

ofthespinalcord

andthe

spinalnerveroots;itwas

similarto

education

materialthathasbeen

researched

elsewhere

andtheeducationcompo

nentsof

back

scho

olsandfunctio

nalrestoratio

nprog

rams

●Roland

Morris

Disability

Questionn

aire

(RMDQ)

●BriefSurvey

ofPain

Attitud

es(revised)(SOPA

(R))

●Pain

Catastroph

ization

Scale(PCS)

●Straight

Leg

Raise(SLR)

(inclinom

eter)

●ForwardBend

ing

Rang

e(Distance

from

long

estfin

-gerto

floor)

●Ab

dominal

Draw

InTask

(ADIT)

Pre-treatm

ent,3weeks

(Con

tinued)

PHYSIOTHERAPY THEORY AND PRACTICE 7

Dow

nloa

ded

by [

Nov

a So

uthe

aste

rn U

nive

rsity

] at

06:

31 3

0 Ju

ne 2

016

Table3.

(Con

tinued).

Participants

Interventio

nsOutcomes

Author

nSample

characteristics

Diagn

ostic

criteria

Treatm

ent

Control

Outcome

instruments

Timeof

assessment

Ryan

etal.(2010)

38●

LBP>3

mon

ths

Educationgroup

●n=18

●11

wom

en●

Age(years)=

45.5

±9.5

●Durationof

pain

(mon

ths)

=13.7

±10.2

Educationand

Exercisegroup

●n=20

●14

wom

en●

Age(years)

45.2

±11.9

●Durationof

pain

(mon

ths)

=7.6±7

NA

PainBiologyOnly

A2.5-ho

urpain

biolog

yeducationsession

Cogn

itive

behavioralinterventio

nfocusedon

reshapingtheparticipant’s

beliefsand

attitud

esabou

ttheirback

pain,attem

ptingto

decrease

fear

avoidanceandharm

beliefs,

increase

self-efficacy,anddecrease

avoidance

behavior

Thebiolog

yof

pain

Verbal

commun

ication,

prepared

diagrams

andfree-handdraw

ings

Additio

nally,all

participants

received

“The

Back

Book”

PainBiologyandExercise

A2.5-

hour

pain

biolog

yeducationsession

Cogn

itive

behavioralinterventio

nfocusedon

reshapingtheparticipant’s

beliefsand

attitud

esabou

ttheirback

pain,attem

ptingto

decrease

fear

avoidanceandharm

beliefs,

increase

self-efficacy,anddecrease

avoidance

behavior

Thebiolog

yof

pain

Verbalcommun

ication,

prepared

diagrams

andfree-handdraw

ings

Additio

nally,allparticipantsreceived

“The

Back

Book”

Exercisecomponent

“Backto

Fitnessexercise

classes”;sixclasses,

oneaweekfor6weeks;the

classesinvolved

circuit-based,

graded,aerob

icexerciseswith

somecore

stability

exercises

Theclassesinvolved

awarm-upph

ase(10

minutes),an

aerobicph

ase(20–30

minutes),

andawarm-dow

nph

ase(10–15

minutes);the

aerobicph

aseinvolved

circuit-basedexercise;

formostexercises,therewas

aneasy,

mod

erate,andhard

version,

andthe

participantcouldchoose

which

versionto

perform

●Roland

Morris

Disability

Questionn

aire

(RMDQ)

●Num

ericRatin

gScale(NRS)

●Repeated

sit-to-

standtest

●The50-footwalk

test

●5-minutewalk

test

●Tampa

Scaleof

Kinesiop

hobia

(TSK-13)

●Pain

Self-Efficacy

Questionn

aire

(PSEQ)

●Step

coun

t(activPA

L™activ-

itymon

itor)

Pre-treatm

entand8weeks

later,3mon

thslater

Meeus

etal.(2010)

46●

Chronicfati-

guesynd

rome

andwide-

spread

pain

●Wom

en:EG=

22andCG

=18

●Ag

e(years):

EG=38.3

±10.6andCG

=42.3

±10.2

1994

Centersfor

Disease

Control

andPreventio

ncriteria

forCFS

(Fukud

aet

al.,

1994)

PainPhysiology

One

30-m

inuteinteractivesession

Physiology

ofthenervou

ssystem

ingeneral

andof

thepain

system

inparticular

Thetheoretic

inform

ationwas

illustrated

with

pictures

andexam

ples

Theob

jectiveof

theeducationwas

toteach

patientsthefunctio

n,mechanism

s,and

mod

ulationof

(chron

ic)pain,and

soforth

PacingandSelf-Management

One

30-m

inuteinteractivesession;pacing

and

self-managem

enteducationwas

provided

toallp

articipantsin

thecontrolg

roup

;pacingis

astrategy

inwhich

patientsareencouraged

toachievean

approp

riate

balancebetween

activity

andrest

inorderto

avoid

exacerbatio

nandto

setrealistic

goalsfor

increasing

activity;followingthisenergy

managem

entstrategy,p

atientsshou

ldavoid

activities

atan

intensity

that

exacerbates

symptom

s,or

they

shou

ldintersperse

activities

with

perio

dsof

rest

●Neuroph

ysiology

ofPain

Test

●Pain

Catastroph

ization

Scale(PCS)

●Pain

Coping

Inventory(PCI)

●Tampa

Scaleof

Kinesiop

hobia

(TSK)

●Pain

Threshold

Assessment

(Fisher

algo

meter)

Pre-treatm

entand

immediatelypo

st-

treatm

ent

(Con

tinued)

8 A. LOUW ET AL.

Dow

nloa

ded

by [

Nov

a So

uthe

aste

rn U

nive

rsity

] at

06:

31 3

0 Ju

ne 2

016

Table3.

(Con

tinued).

Participants

Interventio

nsOutcomes

Author

nSample

characteristics

Diagn

ostic

criteria

Treatm

ent

Control

Outcome

instruments

Timeof

assessment

Vibe

Fersum

etal.

(2013)

94●

Non

-specific

low

back

pain

>3mon

ths

Classification-

basedCognitive

Functional

Therapygroup

(CB-CFT)

●27

wom

enand24

men

●Ag

e(years):

41.0

±10.3

ManualTherapy

andExercise

group(MT-EX)

●21

wom

enand22

men

●Ag

e(years):

42.9

±12.5

NA

CB-CFT

group

Acogn

itive

compo

nent

basedon

finding

sfrom

OrebroMusculoskeletal

Pain

Questionn

aire

Specificmovem

entexercisesas

directed

bythemovem

entclassification

Targeted

functio

nalintegratio

nof

activities

indaily

life

Physicalactivity

prog

ram

tailoredto

the

movem

entclassification;

initialsessionof

1ho

ur,follow-ups

30–45minutes;patientsseen

weeklyforfirst

2–3weeks

andthen

prog

ressed

toon

esessionever

2–3weeks

for

12-weekinterventio

nperio

d;meannu

mberof

treatm

ents

7.7(range

4–16;SD2.6)

MT-EX

group

Jointmob

ilizatio

nor

manipulationtechniqu

esto

spineor

pelvisbeston

currentmanual

therapypractice;generale

xerciseof

motor

controle

xercises;m

otor

controle

xercises

involvingisolated

contractions

ofdeep

abdo

minalmuscles

indiffe

rent

functio

nal

positio

ns;initialsession

,1ho

ur,follow-ups,30

minutes;m

eannu

mberof

treatm

ents

8.0

(range

3–17;SD2.9)

Primaryoutcom

emeasures

●Osw

estry

Disability

Index

(ODI)

●Pain

Intensity

Num

ericRatin

gScale(PINRS)

Secondaryoutcom

es●

Hop

kins

Symptom

sCh

ecklist(HSCL-

25)

●Fear-Avoidance

Belief

Questionn

aire

(FAB

Q)

●Totallum

bar

spinerang

eof

motion

●Patient

satisfaction

●Sick-leavedays

●Care-seeking

Baseline,po

st12-week

interventio

nand12

mon

thspo

st-in

terventio

n

(Con

tinued)

PHYSIOTHERAPY THEORY AND PRACTICE 9

Dow

nloa

ded

by [

Nov

a So

uthe

aste

rn U

nive

rsity

] at

06:

31 3

0 Ju

ne 2

016

Table3.

(Con

tinued).

Participants

Interventio

nsOutcomes

Author

nSample

characteristics

Diagn

ostic

criteria

Treatm

ent

Control

Outcome

instruments

Timeof

assessment

Gallagh

eret

al.

(2013)

79●

Pain

sufficient

todisrup

tactivities

ofdaily

livingfor

>than

pre-

viou

s3

mon

ths

Metaphorsgroup

●n=40

(26

female)

●Ag

e(years):

42±11

●Durationof

pain

(mon

ths):

25±19

Advicegroup

●n=39

(22

female)

●Ag

e(years):

45±11

●Durationof

pain

(mon

ths):

31±20

NA

Booklet1

Metapho

rsandstoriesto

help

understand

the

biolog

yof

pain

Materialfrom

PainfulY

arns:8

0pagesdivided

in11

sections

Readability

onGun

ning

FogIndexwas

7

Booklet2

Advice

abou

tmanagingpain;m

ateriald

rew

from

TheBack

Book

andManageYour

Pain;80

pagesdividedin

11sections;readabilityon

Gun

ning

FogIndexwas

8

Primaryoutcom

emeasures

●Pain

Biolog

yQuestionn

aire

(PBQ

)●

Pain

Catastroph

izing

Scale(PCS)

Secondaryoutcom

es●

Pain

(11-po

int

numericscale)

●Patient-Specific

Functio

nalS

cale

(PSFS)

Baseline,3weeks

and12

weeks

Controlg

roup

cross-over:

15weeks

and24

weeks

(Con

tinued)

10 A. LOUW ET AL.

Dow

nloa

ded

by [

Nov

a So

uthe

aste

rn U

nive

rsity

] at

06:

31 3

0 Ju

ne 2

016

Table3.

(Con

tinued).

Participants

Interventio

nsOutcomes

Author

nSample

characteristics

Diagn

ostic

criteria

Treatm

ent

Control

Outcome

instruments

Timeof

assessment

VanOosterwijcket

al.

(2013)

30●

Fibrom

yalgia

Experim

ental

group

●n=15

(12

wom

en)

●Ag

e(years):

45.8

±9.5

●Durationof

onset

(mon

ths):1

56±96

Controlgroup

●n=15

(14

female)

●Ag

e(years):

45.9

±11.5

Durationof

onset

(mon

ths):1

16±46

1990

American

College

ofRh

eumatolog

y(ACR

)criteria

Experim

entalg

roup

received

educationon

pain

neurop

hysiolog

y;received

inoral

form

atwith

writtenleafletcontaining

inform

ation

andencouraged

totake

homeandread

severaltimes;1

weeklatersecond

interventio

ndelivered

over

theph

one

Controlg

roup

received

educationon

pacing

self-managem

enttechniqu

es;receivedin

oral

form

atwith

writtenleafletcontaining

inform

ationandencouraged

totake

home

andread

severaltimes;1

weeklatersecond

interventio

ndelivered

over

theph

one

Primaryoutcom

emeasures

●Spatial

summa-

tion

procedures

(SSP)

●Fibrom

yalgia

Impact

Questionn

aire

(FIQ)

●Medical

Outcomes

Short

Form

36Health

Status

Survey

(SF-36)

●Pain

Coping

Inventory(PCI)

●Pain

Catastroph

izing

Scale(PCS)

●Pain

Vigilance

andAw

areness

Questionn

aire

(PVA

Q)

●Tampa

Scale

Kinesiop

hobia

(TSK)

●Neuroph

ysiology

ofPain

Test

Secondaryoutcom

es●

Pain

Pressure

Threshold

Baseline,2weeks,3

mon

ths

(Con

tinued)

PHYSIOTHERAPY THEORY AND PRACTICE 11

Dow

nloa

ded

by [

Nov

a So

uthe

aste

rn U

nive

rsity

] at

06:

31 3

0 Ju

ne 2

016

Table3.

(Con

tinued).

Participants

Interventio

nsOutcomes

Author

nSample

characteristics

Diagn

ostic

criteria

Treatm

ent

Control

Outcome

instruments

Timeof

assessment

Ittersum

etal.(2014)

105

●Fibrom

yalgia

Pain

Neuroscience

Educationgroup

●n=53

(50

female)

●Ag

e(years):

47.6

±9.1

●Illness

dura-

tion(years):

8.5

Relaxation

Educationgroup

●n=52

(48

female)

●Ag

e(years):

45.8

±9.8

●Illness

dura-

tion(years):

8.0

American

College

ofRh

eumatolog

y(ACR

)criteria

Pain

NeuroscienceEducationreceived

aneducationalb

ooklet

with

writtenand

illustrated

inform

ationon

painph

ysiology

and

themechanism

sof

centralsensitization;

educationalb

ooklet

explainedstructureand

functio

nof

nervou

ssystem

anddiffe

rence

betweenno

ciceptionandpain;central

sensitizatio

nisintrod

uced

ashypersensitivity

ofthenervou

ssystem

throug

hmetapho

r;explainedfactorsat

onsetandmaintenance

ofcentralsensitization;

threecase

exam

ples

used

toexplainho

wto

usethisinform

ationin

daily

life;bo

okletof

15pages,and

encouraged

toread

severaltimes;received

follow-upsupp

ortin

gteleph

onecall2weeks

post

receivinginform

ation

Relaxatio

neducationgrou

preceived

written

inform

ationon

relaxatio

nexercise

and

instructions

onho

wto

perform

such

exercises;

Loeser’smod

elof

pain

used

tobriefly

explain

physicalandpsycho

logicalfactorswith

chronicpain;b

ooklet

15pages,and

encouraged

toread

severaltimes

andapply

inform

ationin

daily

life;received

follow-up

supp

ortin

gteleph

onecall2weeks

post

receivinginform

ation

Primaryoutcom

emeasures

●Fibrom

yalgia

Impact

Questionn

aire

(FIQ)

Secondaryoutcom

es●

RevisedIllness

Perceptio

nQuestionn

aire

for

FM(IPQ-R_FM)

●Pain

Catastroph

izing

Scale(PCS)

●Patient

opinions

abou

tthebo

ok-

leton

six-po

int

Likertscale

Baseline,6weeks,6

mon

thsfollow-up

Louw

etal.(2014)

67Patientswith

lumbar

radiculopathy

schedu

ledfor

lumbarsurgery

Experim

ental

group

●n=32

●Ag

e(years):

49.59

●Durationof

symptom

s(days):9

1.41

Controlgroup

●n=35

●Ag

e(years):

49.65

●Durationof

symptom

s(days):9

2.29

NA

Pre-op

erativeneuroscience

education(NE)

covered:

(1)decision

tohave

lumbarsurgery;

(2)nervou

ssystem

physiology

andpathways;

(3)perip

heraln

erve

sensitizatio

n;(4)surgical

experiences

andenvironm

entalissues’effects

onnervesensitivity;(5)

calmingthenervou

ssystem

;(6)

recovery

afterlumbarsurgery;(7)

scientificevidence;(8)

reflectionandwriting

questio

nsforsurgeonpriorto

surgery.NE

provided

byph

ysicaltherapistin

one-on

-one

sessionaveraging30

minutes

usingpictures,

exam

ples,m

etapho

rs,and

draw

ings;p

atients

weregivenbo

okletthat

summarized

educationalsession

inform

ationandaskedto

read

atleaston

cebefore

surgery;patients

also

received

“usualcare”regarding

preoperativeeducationfrom

surgeonand

staff

“Usualcare”regardingpreoperativeeducation

from

respectivesurgeonandstaff

Primaryoutcom

emeasures

●Num

ericPain

Ratin

gScales

(NPRS)

●Osw

estry

Disability

Index

(ODI)

Secondaryoutcom

es●

Thou

ghts/beliefs

abou

tsurgery

numericscale(1–

10)

●Health

care

utili-

zatio

nqu

estio

ns

Baseline,1,

3,6,

and12

mon

th(s)

(Con

tinued)

12 A. LOUW ET AL.

Dow

nloa

ded

by [

Nov

a So

uthe

aste

rn U

nive

rsity

] at

06:

31 3

0 Ju

ne 2

016

Table3.

(Con

tinued).

Participants

Interventio

nsOutcomes

Author

nSample

characteristics

Diagn

ostic

criteria

Treatm

ent

Control

Outcome

instruments

Timeof

assessment

Téllez-Garcíaet

al.

(2014)

12●

Chronicno

n-specificlow

back

pain

TrP-DN

group

●n=6(4

female)

●Ag

e(years):

37±13

●Timewith

pain

(mon

ths):

19±8

TrP-DN+EDU

group

●n=6(4

female)

●Ag

e(years):

36±5

●Timewith

pain

(mon

ths):

17±9

NA

Neuroscienceeducationgrou

p(TrP-DN+

EDU)received

30-m

inuteeducationsession,

once

perweekforthelast

twosessions

(treatmentsession2and3)

afterTrP-DN

treatm

ent(asperformed

incontrolg

roup

);face-to-face

individu

alinstructionon

neurop

hysiolog

yof

pain

with

noparticular

referenceto

thelumbarspine;inform

edabou

ttherole

ofbeliefsandattitud

estowardtheir

pain;P

owerPointpresentatio

nbasedon

ExplainPain

was

used;d

uringthesession,

patientswereencouraged

toaskqu

estio

nsto

individu

alizeinform

ation;

writteninform

ation

abou

tpain

physiology

concepts

were

provided

asho

mew

orkbetweensessions

Clinicianwith

10yearsexperienced

intechniqu

edelivered

triggerp

oint-dryneedling

(TrP-DN)do

neto

activetriggerpo

ints

ingluteusmediusandqu

adratuslumbo

rum;

positio

nwas

side

lying,

with

depthof

needle

insertionapproximately20–25mm

and

moved

inmulti-directions

until

first

local

twitchrespon

sewas

obtained;n

eedling

performed

with

upanddo

wnmovem

ent

5–8mm

with

norotatio

nat

approximately1

Hzfor25–30second

s;treatm

entdo

neon

etim

eperweekover

3weeks

Primaryoutcom

emeasures

●Roland

–Morris

Disability

Questionn

aire

(RMDQ)

●Osw

estryLow

Back

Pain

Disability

Index

(ODI)

●Num

erical

Pain

Rate

Scale(NPRS)

●Tampa

Scaleof

Kinesiop

hobia

(TSK)

●Pressure

pain

threshold(PPT)

Baseline,1weekafterlast

interventio

n

(Con

tinued)

PHYSIOTHERAPY THEORY AND PRACTICE 13

Dow

nloa

ded

by [

Nov

a So

uthe

aste

rn U

nive

rsity

] at

06:

31 3

0 Ju

ne 2

016

Table3.

(Con

tinued).

Participants

Interventio

nsOutcomes

Author

nSample

characteristics

Diagn

ostic

criteria

Treatm

ent

Control

Outcome

instruments

Timeof

assessment

Beltran-Alacreu

etal.

(2015)

45●

Non

-specific

chronicneck

pain

Experim

ent

group1

●n=15

(13

female)

●Ag

e(years):

40.9

±16.2

●Pain

duratio

n(m

onths):5

4.9

±57.1

Experim

ent

group2

●n=15

(10

female)

●Ag

e(years):

39.8

±13.4

●Pain

duratio

n(m

onths):8

3.4

(94.1)

Controlgroup

●n=15

(12

female)

●Ag

e(years):

43.5

±15.9

●Pain

duratio

n(m

onths):9

5.8

±77.5

NA

Experim

entalgroup

1(Exp1)

Eigh

ton

e-on

-one

sessions

over

1mon

th;

sametreatm

entas

controlg

roup

with

additio

nof

pain

neuroscience

educationin

twosessions;n

euroscienceeducationbased

onbiob

ehaviorala

pproachdividedinto

three

parts:cogn

itive,o

perant,and

respon

dent;

neuroscience

educationdu

ratio

nwas

approximately20

minutes

foreach

oftwo

sessions;firstsessionon

initialvisitcoverin

gcogn

itive

part;u

seof

PowerPointwith

diagrams,images,and

textswith

education

alon

gwith

inform

ationbo

okletreview

ing

relevant

contentof

educationfrom

first

session;second

sessionon

fifth

visitreview

ing

first

sessionandop

erantandrespon

dent

parts.Operant

sectionexplainedself-

treatm

enttechniqu

esandcoping

strategies

toredu

ceattentionto

pain.

Experim

entalgroup

2(Exp2)

Received

sameinterventio

nas

Experim

ental

grou

p1with

additio

nof

therapeutic

exercise

prog

ram;exerciseprog

ram

basedon

neck

stabilizatio

nexercisesfordeep

neck

flexors

andextensorsandneuralself-mob

ilizatio

ns;

prog

ressiveexercise

prog

ram

was

addedin

sessions

5–8;

with

integrationof

exercise

treatm

entdu

ringtreatm

entsessionmanual

therapy,tim

ewas

halved;p

atientsaskedto

perform

exerciseson

ceperdayat

home

Eigh

ton

e-on

-one

sessions

over

1mon

th;

manualtherapy

techniqu

eswith

specific

passivemovem

ents

ofcervicalfacetjoints,

glob

almob

ilizatio

nof

cervicalspineandhigh

-velocity

techniqu

eto

dorsalspine

Primaryoutcom

emeasure

●NeckDisability

Index(NDI)

Secondaryoutcom

es●

Tampa

Scaleof

Kinesiop

hobia

(TSK)

●Fear

Avoidance

Beliefs

Questionn

aire

(FAB

Q)

●NeckFlexor

Muscle

Endu

rance

(NFM

E)test

●Visual

Analog

Fatig

ueScale

(VAF

S)

Baseline,4,

8,16

weeks

Pireset

al.(2015)

62●

Chroniclow

back

pain

Educationgroup

●n=30

(20

female)

●Ag

e(years):

50.9

±6.2

Controlgroup

●n=32

(20

female)

●Ag

e(years):

51.0

±6.3

NA

Completed

aquatic

exercisesprog

ram

similar

tocontrolw

ithadditio

nof

pain

neurop

hysiolog

yprog

ram;twogrou

psessions,9

0minutes

each;top

icsaddressed:

acutepain

originin

nervou

ssystem

,transition

from

acuteto

chronicpain,central

sensitizatio

n,role

ofbrainin

pain

perceptio

n,cogn

itive

andbehavioralrespon

sesrelatedto

pain,flare-upmanagem

entandpacing

;metapho

rsandpictures

used

throug

hout

the

session

Six-weekprog

ram

of12

biweeklysessions

ofaquatic

exercise;g

roup

sof

6–9participants

lasting30–50minutes;three

phases:(1)

warm-up;

(2)specificexercises;(3)warm-

down

Primaryoutcom

emeasures

●Visual

Analog

ueScale(VAS

)●

QuebecBack

Pain

Disability

Scale

Secondaryoutcom

es●

Tampa

Scaleof

Kinesiop

hobia

(TSK)

Baseline,6weeks

after

beginn

ingprog

ram

and3

mon

thsfollow-up

*EG,experimentalg

roup

;**CG,con

trol

grou

p.

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● Peripheral sensitization (Gallagher, McAuley, andMoseley, 2013; Ittersum et al., 2014; Louw, Diener,Landers, and Puentedura, 2014; Moseley, 2003c;Van Oosterwijck et al., 2013; Vibe Fersum et al.,2013)

● Central sensitization (Gallagher, McAuley, andMoseley, 2013; Ittersum et al., 2014; Louw,Diener, Landers, and Puentedura, 2014; Moseley,2003c; Moseley, Nicholas, and Hodges, 2004;Pires, Cruz, and Caeiro, 2015; Vibe Fersum et al.,2013)

● Plasticity of the nervous system (Gallagher,McAuley, and Moseley, 2013; Louw, Diener,Landers, and Puentedura, 2014; Moseley, 2003c;Moseley, Nicholas, and Hodges, 2004; VanOosterwijck et al., 2013)

● Psychosocial factors and beliefs contributing topain (Beltran-Alacreu, Lopez-de-Uralde-Villanueva,Fernandez-Carnero, and La Touche, 2015;Gallagher, McAuley, and Moseley, 2013; Pires, Cruz,and Caeiro, 2015; Téllez-García et al., 2014; VibeFersum et al., 2013)

The book Explain Pain by Butler and Moseley (2003)was directly referenced in six of the studies (Meeuset al., 2010; Pires et al., 2015; Ryan, Gray, Newton,and Granat, 2010; Téllez-García et al., 2014; VanOosterwijck et al., 2013).

Professionals performing PNEPhysical therapists have been the delivery professionalof PNE in all of the studies found in this review. In onestudy, utilizing booklets, the lead author was anoccupational therapist, but no direct education (otherthan the book, authored by a physical therapist) wasprovided (Gallagher, McAuley, and Moseley, 2013).

Duration and frequency of PNEThe time and frequency of delivery was varied witha shift toward shorter durations found more com-mon in the more recent studies. Longest duration ofthe documented sessions was 4 hours (Moseley,2003c) in one session, with shortest duration beingaround 30 minutes (Louw, Diener, Landers, andPuentedura, 2014; Meeus et al., 2010; Téllez-Garcíaet al., 2014; Van Oosterwijck et al., 2013). Shortestfrequency was one time educational session(Moseley, Nicholas, and Hodges, 2004; Pires, Cruz,and Caeiro, 2015) with other studies utilizing edu-cation spread out over multiple episodes during thecourse of treatment.

Educational format and toolsThe primary format for delivery of PNE was verbalone-on-one between patient and provider; two studiesutilized group sessions (Moseley, 2003c; Pires, Cruz,and Caeiro, 2015) and one study did not have anyface-to-face contact and only the information from abook that was read by the subjects (Gallagher,McAuley, and Moseley, 2013). The one-on-onesessions were most often described in terms of con-versational, with encouragement for subjects to askquestions, so material could be individualized andnot a straight lecture format. Various teaching aidswere used during the delivery of the education con-sisting of prepared pictures, PowerPoint presentations,drawings, examples, metaphors, and books comple-menting the in person education information.

Adjunct treatment to PNEDifferent study methodologies were used in the studiesunder review. The use of PNE was used in conjunctionwith other active movement-based therapy interventionsin many of the studies. The list of other therapeuticactivities used with PNE consisted of:

● Mobilization and manipulation (Moseley, 2002)● Soft tissue massage (Moseley, 2002)● Muscle and neural mobilization (Beltran-Alacreu,

Lopez-de-Uralde-Villanueva, Fernandez-Carnero,and La Touche, 2015; Moseley, 2002)

● Trunk stabilization (Moseley, 2002, 2003c; Ryan,Gray, Newton, and Granat, 2010)

● Circuit-based aerobic exercise (Ryan, Gray,Newton, and Granat, 2010)

● Movement exercises (Vibe Fersum et al., 2013)● Paced/graded exposure with activities of daily

(Meeus et al., 2010; Vibe Fersum et al., 2013)● Trigger point dry needling (Téllez-García et al., 2014)● Neck stabilization exercises (Beltran-Alacreu,

Lopez-de-Uralde-Villanueva, Fernandez-Carnero,and La Touche, 2015)

● Aquatic exercise program (Pires, Cruz, andCaeiro, 2015)

● None (PNE only) (Ittersum et al., 2014; Louw,Diener,Landers, and Puentedura, 2014; Moseley, Nicholas,and Hodges, 2004; Van Oosterwijck et al., 2013)

Outcome measures

Many different outcome measurement tools were usedacross the studies (Table 3) and assessed at various timepoints post-intervention. Measurements periods variedfrom immediate post-intervention to 1 year follow-up.We used the grouping of each of the outcomes

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measurements into the four categories established in theinitial systematic review: pain, function, psychosocialfactors, and movement along with adding a fifth cate-gory of healthcare utilization.

Outcomes related to pain● Pain rating (Numeric Pain Rating Scales or Visual

Analog Scale) (Gallagher, McAuley, and Moseley,2013; Louw, Diener, Landers, and Puentedura,2014; Moseley, 2002; Pires, Cruz, and Caeiro,2015; Ryan, Gray, Newton, and Granat, 2010;Vibe Fersum et al., 2013)

● Pain knowledge (Neurophysiology of PainQuestionnaire or Pain Biology Questionnaire)(Meeus et al., 2010; Van Oosterwijck et al., 2013)

● Pain Vigilance and Awareness Questionnaire (VanOosterwijck et al., 2013)

● Pressure Pain Threshold (Meeus et al., 2010; Téllez-García et al., 2014; Van Oosterwijck et al., 2013)

● Spatial summation procedure (Van Oosterwijcket al., 2013)

Outcomes related to function and disability● Roland Morris Disability Questionnaire (Moseley,

2002, 2003c; Ryan, Gray, Newton, and Granat,2010; Téllez-García et al., 2014)

● Oswestry Disability Index (Louw, Diener, Landers,and Puentedura, 2014; Téllez-García et al., 2014;Vibe Fersum et al., 2013)

● Neck Disability Index (Beltran-Alacreu, Lopez-de-Uralde-Villanueva, Fernandez-Carnero, and LaTouche, 2015)

● Fibromyalgia Impact Questionnaire (Ittersumet al., 2014; Van Oosterwijck et al., 2013)

● Revised Illness Perception Questionnaire forFibromyalgia (Ittersum et al., 2014)

● Short Form 36 Health Status Survey (VanOosterwijck et al., 2013)

● Quebec Back Pain Disability (Pires, Cruz, andCaeiro, 2015)

● Patient-Specific Functional Scale (Gallagher,McAuley, and Moseley, 2013)

Outcomes related to psychosocial factors● Tampa Scale of Kinesiophobia (Beltran-Alacreu,

Lopez-de-Uralde-Villanueva, Fernandez-Carnero,and La Touche, 2015; Meeus et al., 2010; Pires,Cruz, and Caeiro, 2015; Van Oosterwijck et al.,2013)

● Pain Catastrophization Scale (Gallagher, McAuley,and Moseley, 2013; Ittersum et al., 2014; Moseley,Nicholas, and Hodges, 2004)

● Pain Coping Inventory (Meeus et al., 2010; VanOosterwijck et al., 2013)

● Survey of Pain Attitudes (revised) (Moseley,Nicholas, and Hodges, 2004)

● Pain Self-Efficacy Questionnaire (Ryan, Gray,Newton, and Granat, 2010)

● Hopkins Symptoms Checklist (Vibe Fersum et al.,2013)

● Fear Avoidance Beliefs Questionnaire (Beltran-Alacreu, Lopez-de-Uralde-Villanueva, Fernandez-Carnero, and La Touche, 2015; Vibe Fersum et al.,2013)

● Beliefs about surgery (Louw, Diener, Landers, andPuentedura, 2014)

Outcomes related to movement● Straight leg range of motion (Moseley, Nicholas,

and Hodges, 2004)● Lumbar range of motion (Moseley, Nicholas, and

Hodges, 2004; Vibe Fersum et al., 2013)● Abdominal draw in task (Moseley, Nicholas, and

Hodges, 2004)● Repeated sit to stand test (Ryan, Gray, Newton,

and Granat, 2010)● 50-foot walk test (Ryan, Gray, Newton, and

Granat, 2010)● 5-minute walk test (Ryan, Gray, Newton, and

Granat, 2010)● Step count (Ryan, Gray, Newton, and Granat,

2010)● Neck flexor muscle endurance test (Beltran-

Alacreu, Lopez-de-Uralde-Villanueva, Fernandez-Carnero, and La Touche, 2015)

● Visual Analog Fatigue Scale (Beltran-Alacreu,Lopez-de-Uralde-Villanueva, Fernandez-Carnero,and La Touche, 2015)

Outcomes related to healthcare utilization● Healthcare center visits (Moseley, 2002)● Sick-leave days (Vibe Fersum et al., 2013)● Care-seeking (Vibe Fersum et al., 2013)● Healthcare utilization questions (Louw, Diener,

Landers, and Puentedura, 2014)

Effectiveness of PNE

Results could not be pooled for all the studies due tothe variability in outcome measurement tools and dif-fering control groups. Results of outcomes are summar-ized in Table 4.

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Table4.

Effectivenessof

PNEon

pain,d

isability,anxiety,and

stress

forMSK

cond

ition

s.

Outcome

Moseley

(2002)

Moseley

(2003c)

Moseley

etal.(2004)

Ryan

etal.

(2010)

Meeus

etal.

(2010)

Vibe

Fersum

etal.(2013)

Gallagh

eret

al.(2013)

VanOosterwijk

etal.(2013)

Ittersum

etal.(2014)

Louw

etal.

(2014)

Téllez-García

etal.(2014)

Beltran-Alacreu

etal.(2015)

Pires

etal.

(2015)

Decreasein

pain

ratin

gs+

++

+0

00

+Increase

pain

tolerance

0+

0Increase

know

ledg

eof

pain

++

+Improvefunctio

nand

disability

++

+0

+0

+0

00

+0

Decreasefear

ofmovem

ent

00

+0

++

0Decreasepain

catastroph

ization

++

+0

0

Develop

strategies

tocope

with

pain

00

Develop

healthyattitud

esregardingpain

+0

+

Decreaseanxietyand/or

depression

symptom

s+

Improveph

ysical

movem

entand

performance

+0

0+

Decreasehealth

care

utilizatio

n+

++

+,p

ositive

effectiveness;0,

noeffectiveness.

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PNE addressing painTen of the 13 studies evaluated the effect of PNE onpain of the subjects.

(1) The mean improvement of pain at 1 monthwas 1.5 on the NRS (95% CI: 0.7–2.3) forthose receiving the intervention over those inthe control group. This difference was shownto have a significant treatment effect (p <0.01) with a number needed to treat to gainclinical significance at 3 (95% CI: 2–8). At 1year follow-up, this difference maintained inregards to improvement with pain 1.9 (95%CI: 1–2.8) with number needed to treat of2 (95% CI: 1–4) (Moseley, 2002).

(2) Significant decrease in pain on NRS from5-week “on-going usual treatment” to end of4-week treatment intervention and 12-monthfollow-up. Individual education group showedtreatment effect of 3.1 (95% CI: 1.8–4.2) onNRS at conclusion of 4-week intervention andgroup education group showed 2.7 (95% CI:1.6–3.9) reduction on NRS. The differencebetween pre-treatment and post-treatmentbetween independent and group treatmentwas 1.0 (95% CI: 0.3–2.0) (Moseley, 2003c).

(3) There was a significant time and groupinteraction from pre-test to post-1-monthfollow-up for PNE group over control groupof exercise and traditional education groupwith decrease in NRS. This difference leveledoff at the 3 months post-intervention timemeasurement point (Ryan, Gray, Newton,and Granat, 2010).

(4) Pressure pain threshold decreased in bothgroups over time but no between-groupdifferences were found at the end of theintervention. Significant difference in painneuroscience knowledge in experimentalgroup over control group (p < 0.001) wasfound (Meeus et al., 2010).

(5) Both treatment groups showed significantimprovement with respect to improved painratings with the PNE group showing statisti-cally (p < 0.001) superior outcomes comparedwith traditional therapy group at 3 and 12months follow-up. The mean differencebetween groups for 3 and 12 months, respec-tively, for PINRS were 2.1 (95% CI: 2.7–1.4)and 1.3 (95% CI: 2.1–0.5) (Vibe Fersum et al.,2013).

(6) Analysis showed that both groups improvedover time in NRS but there was no significant

effect between groups in regards to pain withreading either the PNE book or control book.Increased knowledge about pain biology inthe experimental group over advice group(p < 0.01) was seen with an effect size ofCohen d = 1.7 (Gallagher, McAuley, andMoseley, 2013).

(7) Spatial summation procedure showed no signif-icant differences at 2 weeks post-interventionwith PNE compared with control, but therewas a significant difference at 3 months (p =0.041). There was no significant difference inpressure pain threshold or Pain vigilance andAwareness Questionnaire between groups overassessment periods. Neurophysiology of paintest showed significant increase in responsewith experimental group (p < 0.001) but notcontrol group (p = 0.150) (Van Oosterwijcket al., 2013).

(8) There was no significant effect for low back orleg pain between PNE group and controlgroup over the 12-month time. Overall timeeffects for decreased pain for both groupswere significant (p < 0.002). There was shortterm (1 month follow-up) effect with signifi-cant decrease in pain for low back and leg (p <0.046) but plateaued over the 3, 6, and 12months follow-up (Louw, Diener, Landers,and Puentedura, 2014).

(9) No group interaction for pain intensity wasfound between trigger point dry needlinggroup with PNE (−3.6 (95% CI: −6.0 to−1.1)) or without PNE (−4.2 (95% CI: −6.6to −1.7)) but time interaction was foundsignificant for both groups (p < 0.002).There was no group interaction differencesfor pressure pain threshold measurementsbut there was significant time interactionpost-treatment at all three measurementpoints (Téllez-García et al., 2014).

(10) Statistical differences were found for overallgroup interaction by time and also between-group interaction at 3 months follow-upfavoring the PNE group but none at 6 weeksfollow-up on the visual analog scale. Visualanalog change at 3 months for educationgroup compared with control group was−25.4 ± 26.7 and −6.6 ± 30.7, respectively(Pires, Cruz, and Caeiro, 2015).

PNE addressing functionTwelve of the 13 studies addressed function throughvarious functional measurement tools. Six studies

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looked at general functional improvement scoresthrough use of Roland Morris DisabilityQuestionnaire (RMDQ) (Moseley, 2002; Moseley,Nicholas, and Hodges, 2004; Ryan, Gray, Newton, andGranat, 2010; Téllez-García et al., 2014) or Short Form36 Health Status Survey (SF-36) (Van Oosterwijcket al., 2013). Eight of the studies used more specificquestionnaires based on diagnostic or functional status.The diagnostic or specific functional measurementtools used were (1) Oswestry Disability Index (ODI)(Louw, Diener, Landers, and Puentedura, 2014; Téllez-García et al., 2014; Vibe Fersum et al., 2013); (2) NeckDisability Index (NDI) (Beltran-Alacreu, Lopez-de-Uralde-Villanueva, Fernandez-Carnero, and LaTouche, 2015); (3) Patient-Specific Functional Scale(PSFS) (Gallagher, McAuley, and Moseley, 2013); (4)Fibromyalgia Impact Questionnaire (FIQ) (VanOosterwijck et al., 2013); (5) Revised IllnessPerception Questionnaire for Fibromyalgia (IPQ-R_FM) (Ittersum et al., 2014); and (6) Quebec BackPain Disability Scale (Pires, Cruz, and Caeiro, 2015).

(1) Both groups improved in regards to disabilitywith mean improvement of the interventiongroup over control of 3.9 points on theRMDQ (95% CI: 2.0–5.8). With numberneeded to treat of 2 (95% CI: 2–5) for theRMDQ (Moseley, 2002).

(2) Between-group change favored the interven-tion group with a mean effect of 2.4 (95% CI:0.8–4.2) on the RMDQ (Moseley, 2003c).

(3) Experimental group improved in RMDQ by 2points (95% CI: 0.4–3.6) compared with con-trol group post-treatment (Moseley, Nicholas,and Hodges, 2004).

(4) There was a non-significant trend toward amore favorable outcome with experimentalgroup in improvement of RMDQ (p = 0.127)(Ryan, Gray, Newton, and Granat, 2010).

(5) Both groups showed significant improvementover time with treatment for ODI scores. Thegroup receiving PNE had a significant (p <0.001) mean difference improvement of −9.7(95% CI: −12.7 to −6.7) at 3 months and −8.2(95% CI: −12.6 to −3.8) at 12 months comparedwith the other group ODI score. The groupreceiving PNE showed an overall ODIimprovement over 12 months of 13.7 (95% CI:11.4–16.1; p < 0.001) (Vibe Fersum et al., 2013).

(6) Both groups improved over time in regardsto disability as measured through PSFS, butno differential effect between groups was

found (p = 0.07) (Gallagher, McAuley, andMoseley, 2013).

(7) Significant between-group differences werefound in favor of experimental group for SF-36 physical functioning (p = 0.046), generalhealth perceptions (p < 0.001), and vitality (p= 0.047) subscores. A large effect size (Cohend) was found for the SF-36 health perceptionsscale (d = −0.98). The remaining SF-36 sub-scores and FIQ did not show significanteffects for between-group differences (VanOosterwijck et al., 2013).

(8) No significant effects were found betweengroups for FIQ, and all effect sizes for FIQdomains were small. Illness perception asmeasured through IPQ-R_FM did not showany statistically different effects betweengroups (Ittersum et al., 2014).

(9) There was no significant between-groupinteraction (p > 0.167), both groups showedimprovement over time in regards to functionas measured with ODI (p < 0.002) (Louw,Diener, Landers, and Puentedura, 2014).

(10) ODI scores showed no significant groupinteraction changes for ODI (p = 0.542) orRMDQ (p = 0.111). There was a main effectfor time for both groups for ODI (p < 0.001)and RMDQ (p < 0.001) (Téllez-García et al.,2014).

(11) NDI showed significant improvement (p <0.01) for both experimental groups comparedwith control group at the 4, 8, and 16 weeksfollow-ups (Beltran-Alacreu, Lopez-de-Uralde-Villanueva, Fernandez-Carnero, andLa Touche, 2015).

(12) Functional disability showed significant (p <0.05) group by time interaction but no statisti-cally significant between-groups difference at 6weeks (p = 0.83) or 3 months (p = 0.09). Agreater percent of participants in PNE reportedbenefits from treatment for functional disabilityat both measurement points with only the 3months follow-up showing significant (p =0.034) findings (Pires, Cruz, and Caeiro, 2015).

PNE addressing psychosocial factorsOutcomes related to psychosocial factors were mea-sured in 11 of the 13 studies. Researchers choose amixture of validated tests consisting: (1) PainCatostrophizing Scale (PCS) (Gallagher, McAuley, andMoseley, 2013; Ittersum et al., 2014; Meeus et al., 2010;Moseley, Nicholas, and Hodges, 2004; Van Oosterwijck

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et al., 2013); (2) Pain Coping Index (PCI) (Meeus et al.,2010; Van Oosterwijck et al., 2013); (3) Tampa Scale ofKinesiophobia (TSK) (Beltran-Alacreu, Lopez-de-Uralde-Villanueva, Fernandez-Carnero, and LaTouche, 2015; Meeus et al., 2010; Pires, Cruz, andCaeiro, 2015; Ryan, Gray, Newton, and Granat, 2010;Téllez-García et al., 2014; Van Oosterwijck et al., 2013);(4) Pain Self-Efficacy Questionnaire (PSEQ) (Ryan,Gray, Newton, and Granat, 2010); (5) Fear AvoidanceBeliefs Questionnaire (FABQ) (Beltran-Alacreu, Lopez-de-Uralde-Villanueva, Fernandez-Carnero, and LaTouche, 2015; Vibe Fersum et al., 2013); (6) Survey ofPain Attitudes (revised) (SOPA(R)) (Moseley, Nicholas,and Hodges, 2004); (7) Hopkins Symptoms Checklist(HSCL-25) (Vibe Fersum et al., 2013); and (8) Beliefsabout surgery questionnaire (Louw, Diener, Landers,and Puentedura, 2014).

(1) Both SOPA(R) and PCS were better in theexperimental group compared with controlgroup (p < 0.001 for both). Effect size forSOPA(R) total was 9.0 (95% CI: 6.5–11.5)and for PCS was 6.0 (95% CI: 3.8–8.2)(Moseley, Nicholas, and Hodges, 2004).

(2) No statistically significant effect for PSEQ orTSK-13 was found (Ryan, Gray, Newton, andGranat, 2010).

(3) Significant reduction (p = 0.009) in PCS forruminating scale in the PNE group comparedwith control, coping strategies (PCI) trendedtoward significance with “distraction” (p =0.021) and worrying (p = 0.011). The TSKdid not reach significance levels when com-paring groups (Meeus et al., 2010).

(4) FABQ for physical subscales showed significantchanges favoring experimental group at 3months: −3.6 (95% CI: −5.3 to −1.9; p < 0.001)and at 12 months −4.7 (95% CI: −6.5 to −3.0; p <0.001). Work subscale of the FABQ alsoshowed favorable results toward experimentalgroup at both time measurement intervals −5.7(95% CI: −7.8 to −3.6; p < 0.001) and −5.6 (95%CI: −8.7 to −2.5, p < 0.001), respectively. TheHSCL-25 also showed significant results at3 months: −0.12 (95% CI: −0.19 to −0.04) andat 12 months: −0.13 (95% CI: −0.22 to −0.04) infavor of the experimental group (Vibe Fersumet al., 2013).

(5) A large significant shift (p < 0.01) in PCSscores was found in pain metaphor groupcompared with control advice group initiallyand at 3 months follow-up, with large effectsize at 3 months follow-up (Cohen d = 0.7).

When the control group was crossed over tometaphor group, it also showed significant(p < 0.01) improvements in PCS (Gallagher,McAuley, and Moseley, 2013).

(6) Mean scores of PCI and TSK decreased withtreatment as they did not reach significance forbetween-group differences (Van Oosterwijcket al., 2013).

(7) In regards to PCS, there were no between-group or within-group changes found(Ittersum et al., 2014).

(8) Main effect for more favorable post-operativeopinion in experimental group over controlgroup was found on three questions: “fullyprepared for surgery” (p = 0.01), “preopera-tive education prepared well” (p = 0.001), and“met expectations” (p = 0.042) (Louw, Diener,Landers, and Puentedura, 2014).

(9) Treatment with PNE had greater reduction (p= 0.008) of kinesiophobia than those treatedwithout PNE. Between-group change was infavor of PNE on TSK (−12.7 (95% CI: −21.3to −4.0)) (Téllez-García et al., 2014).

(10) With TSK there were significant effects (p <0.05) for post-treatment, 8 and 16 weeksfor favoring experimental 1 to control. Also,similar significant effects of TSK favoringexperimental 2 versus control at 8 and 16weeks were found. There were no differencesin TSK when comparing the two experimentalgroups. Effect size of experimental group 1 forTSK was d = 1.22, while it was d = 1.02 forexperimental group 2. Significance (p < 0.5) forFABQ was similarly in favor of experimentalgroup 1 and 2 over control with differencebetween the two experimental groups. Effectsize for experimental 1 was d = 0.78 and forexperimental 2 was d = 1.13 (Beltran-Alacreu,Lopez-de-Uralde-Villanueva, Fernandez-Carnero, and La Touche, 2015).

(11) No statistical interaction was found with TSK(Pires, Cruz, and Caeiro, 2015).

PNE addressing movementFour of the studies looked specifically at an impairmentin movement. All four studies chose different physicalperformance tasks to study effects.

(1) Forward bending and straight leg raise wereimproved more in the experimental groupover the control group (p < 0.001 for both).Abdominal “drawing-in” task did not show

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between-group differences (Moseley, Nicholas,and Hodges, 2004).

(2) Physical performance measurements ofrepeated sit-to-stand test, 50-foot walk test,and 5-minute walk test did not show any sig-nificant changes between the experimental andcontrol group (Ryan, Gray, Newton, andGranat, 2010).

(3) No significant changes between the experimen-tal and control group were found at 3 months(Vibe Fersum et al., 2013).

(4) Visual Analog Fatigue Scale (VAFS) and NeckFlexor Muscle Endurance Test (NFME) showedsignificant effects (p < 0.05) at 8 and 16 weeksfollow-up. Experimental group 1 was signifi-cant (p < 0.01) for VAFS and NFME. In experi-mental group 2, the NFME test was significant(p < 0.01) but not for VAFS (Beltran-Alacreu,Lopez-de-Uralde-Villanueva, Fernandez-Carnero, and La Touche, 2015).

PNE addressing healthcare utilizationThree studies explored changes in healthcare utilizationfollowing PNE. Each study utilized different outcomemeasurements for their study design.

(1) At 1 year follow–up, experimental group made3.6 ± 2 (mean ± SD) healthcare center visits forlow back pain, which was statistically less (p <0.001) than the control group who made 13.2 ±5 visits (Moseley, 2002).

(2) Reduction of sick-leave days extracted from theOrebro Screening Questionnaire was observedwith significance (p < 0.01) toward the experi-mental group (z = 2.95). Also improved (p <0.001) reduction in care-seeking after interven-tion was noticed (z = 4.79) (Vibe Fersum et al.,2013).

(3) Overall reduction in healthcare costs for med-ical treatment at 1 year follow-up was less forexperimental group (mean = $22678.57, SD =$3135.30) compared with control group (mean= $4833.48, SD = $3256.00) (z = −2.700, p =0.007) (Louw, Diener, Landers, andPuentedura, 2014).

Discussion

The results of this updated systematic review of PNEfor MSK pain provide supporting evidence for PNEimproving pain ratings, pain knowledge, disability,pain catastrophization, fear-avoidance, attitudes and

behaviors regarding pain, physical movement, andhealthcare utilization (Ezzo et al., 2000; Fernández-de-las-Peñas et al., 2006). These positive results need,however, to be considered in lieu of the heterogeneousnature of the studies included in this systematic review.It is also important to recognize that no PNE studyshowed any outcome to be worse than the controlgroups, thus implying a significant risk–benefit ratioin favor of PNE. In comparison with the previous twosystematic reviews, however, the quality of the studies,number of studies, and total number of patients (n =734) are substantially increased (Clarke, Ryan, andMartin, 2011; Louw, Diener, Butler, and Puentedura,2011). This increase not only reflects the increasedactivity in this field of study but also impacts theconclusions that can be made in regards to the efficacyof PNE. For example, in the systematic review by Louw,Diener, Butler, and Puentedura (2011) which includedlower-level studies (pseudo-RCT, case–control), theefficacy of PNE addressing pain was reported as “com-pelling,” whereas the current review using higher-levelRCTs showcases a similar and even increased effect onreducing pain ratings.

Various noteworthy observations can be made. First,only three studies reported 1 year outcomes, and inter-estingly, also reported on healthcare utilization (Louw,Diener, Landers, and Puentedura, 2014; Moseley, 2002;Vibe Fersum et al., 2013). All three studies showed asignificant reduction of healthcare utilization 1 yearafter PNE. Given the various concerns regardinghealthcare cost in general, there is an ever-increasingrequest for treatments that are cheaper, easily accessi-ble, and have long-lasting efficacy. Pain is complex, andwith well-documented issues such as central sensitiza-tion, neuroplasticity, changes in endogenous mechan-isms, etc., using pain ratings alone as a measure ofimprovement seems illogical. Even though evidencesupports the reduction over time of pain with theutilization of PNE, a sudden, total resolution of painis biologically questionable. The concept of reconcep-tualizing pain, a cornerstone of PNE, aims to havepatients see their pain differently. This implies thateven though they still experience pain, they thinkdifferently about it, equating it to sensitization of thenervous system versus the health of the tissues.Furthermore, this reconceptualization imparts a mes-sage of “despite the pain,” it is worthwhile to move,exercise, engage, and continue in daily activities andnot necessary to seek additional care for the sensitiza-tion (pain). This behavior change is the key to changingany patient’s healthcare status, that is, smoking, weightgain, etc. In line with the results from this systematicreview and the three RCTs being discussed, it is argued

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that true behavior change is reflected in healthcareutilization. Given the relative low cost of “only” educa-tional sessions with a physical therapist, the ability tohave such a huge impact, especially 1 year, out needsmention. In contrast, these three studies also highlightthe need for more long-term studies on the efficacy ofPNE to measure its true impact. To date, the authorsare only aware of one PNE study extending beyond 1year outcome, with Louw, Diener, Landers, andPuentedura (2014) measuring 3-year outcomes ofpreoperative PNE for patients undergoing surgery forlumbar radiculopathy.

The second observation highlights the possible differ-ences between education-only approaches of PNE versusPNE combined with a movement-based strategy such asexercise and/or manual therapy. In five studies, patientsreceived education-only intervention (Gallagher,McAuley, and Moseley, 2013; Ittersum et al., 2014;Louw, Diener, Landers, and Puentedura, 2014;Moseley, Nicholas, and Hodges, 2004; Van Oosterwijcket al., 2013). None of these studies had any ability todecrease pain ratings, whereas five of the six studies thatcombined PNE with a physical intervention were able toproduce a significant reduction in pain ratings. In linewith the definition of PNE and the argument that PNE“biologizes” pain, teaching patients about the biologyand physiology of a pain experience would make sense.Education-alone may not be sufficient for change. This isimportant as many clinicians may be under the impres-sion that PNE is education-only intervention.Additionally, it has been reported that some clinicianssee PNE and pain science as “hands-off” versus “hands-on.” This review strongly suggests that the combinationof PNE with movements, be it passive and/or active, maybe a key in the success of PNE. Further studies areneeded to explore this finding.

Various issues in regards to questions and potentialfuture avenues associated with PNE research are foundin the results of this systematic review. The obviousshortcoming is the heterogonous studies regardingdesign, patient populations, outcome measures, educa-tional delivery methods, etc. By standardization of thesefactors, subsequent reviews and meta-analysis may shedfurther light on the efficacy of PNE. An interestingobservation is that three studies examined and showedan increase in pain knowledge, yet this increasedknowledge of pain has yet to be shown to correlate todecreased pain and disability. Of the three studies thatreported increased knowledge of pain, it is, however,interesting to note that both Meeus et al. (2010) andGallagher, McAuley, and Moseley (2013) showed anincrease in pain knowledge as well as a positive effectof their PNE on pain catastrophization. This increase of

pain knowledge and its potential effect warrants furtherinvestigation. Additionally, in line with current trendsof MSK pain treatments, such as low back pain, is therea need to explore sub-grouping of patients? Bothgroups made meaningful changes in regards to variousoutcome measures. Apart from PNE alone not beingeffective in reducing pain ratings, the current reviewdoes not show any meaningful trends beyond this andwarrants further investigation.

Conclusion

Strong evidence supports the use of PNE for MSKdisorders in reducing pain ratings, limited knowledge ofpain, disability, pain catastrophization, fear-avoidance,unhealthy attitudes and behaviors regarding pain, limitedphysical movement and healthcare utilization (Ezzo et al.,2000; Fernández-de-las-Peñas et al., 2006).

Declaration of interest

The authors report no conflicts of interest. The authors aloneare responsible for the content and writing of the paper.

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