search for




 

Effects of pain neuroscience education on kinesiophobia in patients with chronic pain: a systematic review and meta-analysis
Physical Therapy Rehabilitation Science 2020;9:309-17
Published online December 30, 2020
© 2020 Korean Academy of Physical Therapy Rehabilitation Science.

Hyunjoong Kima , Seungwon Leeb

aSports Rehabilitation Center, The Better Hospital, Gwangju, Republic of Korea
bDepartment of Physical Therapy, College of Health Science and Social Welfare, Sahmyook University, Seoul, Republic of Korea
Correspondence to: Seungwon Lee (ORCID https://orcid.org/0000-0002-0413-0510)
Department of Physical Therapy, College of Health Science and Social Welfare, Sahmyook University, 815 Hwarang-ro, Nowon-gu, Seoul 01795, Republic of Korea
Tel: 82-2-3399-1630 Fax: 82-2-3399-1639 E-mail: swlee@syu.ac.kr
Received November 30, 2020; Revised December 7, 2020; Accepted December 8, 2020.
cc This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Objective: One of the treatment strategies for controlling chronic pain and preventing disability is patient education. Pain neuroscience education (PNE) has been proven to be effective in explaining the biological and physiological processes associated with pain experiences to patients. The purpose of this review is to investigate the effectiveness of PNE for kinesiophobia such as avoidance response in patients with chronic pain.
Design: A systematic review and meta-analysis.
Methods: MEDLINE, EMBASE, CINAHL, PEDro, and the Cochrane Central Register of controlled trials databases were searched through November 2020 and included a randomized controlled trials evaluating kinesiophobia in musculoskeletal patients with chronic pain. In 8 randomized controlled trial studies, ‘Cochrane’s risk of bias (RoB) tool was used for qualitative analysis, and results of post-intervention were analyzed through RevMan 5.4 for quantitative analysis.
Results: For this review, 8 randomized controlled trials of 369 patients with chronic pain were selected for PNE. A systematic review and meta-analysis also included 8 randomized controlled trials. The effect on kinesiophobia was more effective than the control group (−0.86; 95% confidence interval [CI], −1.22 to −0.51; heterogeneity [χ2=21.18, df=7, I2=67%]; overall effect [Z=4.80]). In addition, the effect on pain was more effective than the control group (−0.53; 95% CI, −1.05 to −0.01; heterogeneity [χ2=47.42, df=7, I2=85%]; overall effect [Z=2.01]).
Conclusions: The results of this review suggest that PNE and combined PNE have a positive effect on the improvement of pain and kinesiophobia in patients with chronic pain.
Keywords : Chronic pain, Education, Musculoskeletal pain, Neurosciences
Introduction

Musculoskeletal pain (MSP) is caused by complex interactions. Factors that can contribute include mechanical, biomechanical, psychological, and social factors. What the various factors mean is that MSP is affected by external factors other than just tissue damage. Management of MSP includes pharmacological and non-pharmacological (physical, psychological, social/environmental) interventions and invasive (surgical) methods [1].

Chronic pain can be defined as pain lasting more than 6 months [2]. However, there are specific pathological mechanisms involved in the chronicization of MSP. It is important to understand the concept of neuroplasticity (a neuron’s ability to completely alter its structure, function, or biochemical profile in response to repeated afferent sensory inputs) in order to understand the development of chronic pain due to acute pain. This is because local inflammation of the damaged tissue increases the sensitization of special peripheral sensory neurons (nociceptors), inducing repetitive afferent input to the central nervous system [3]. Repetitive input of pain signals leads to the development of chronic pain and affects brain regions that are not related to pain, thereby changing the existing activated patterns (default mode network, DMN) [4]. As such, it has been reported that chronic pain induces escape and avoidance behaviors and is closely correlated with kinesiophobia [5,6].

One of the treatment strategies for controlling chronic pain and preventing disability is patient education [7-10]. Existing musculoskeletal educational models have focused on biomedical education focusing on anatomy, biomechanics and pathologic anatomy [7,11-13]. Biomedical education models have shown limited efficacy in relieving pain and disability [7,11,14,15]. Pain neuroscience education (PNE) [16,17] has been used interchangeably with therapeutic neuroscience education [18,19] and has been used to explain pain [20,21]. PNE aims to explain to the patient the biological and physiological processes involved in the experience of pain, and more importantly, not to focus on issues related to the anatomy [16,17,22-24]. PNE consists of educating patients in neurobiology and neurophysiology in pain and pain processing by the nervous system. It is understood that this may be due to sensitive nerves as it alters the ‘patient’s perception of pain [22,25].

Chronic pain is controversial about the management of pain as it affects areas of the brain that are not related to pain and alters the DMN. Therefore, it was hypothesized that understanding and learning of their pain could be effective in controlling pain through behavioral changes by changing the DMN for patients with chronic pain. Therefore, in this study, the effect of PNE on kinesiophobia, such as avoidance response in patients with chronic pain, can be identified and used as basic data to suggest the direction of the intervention program in the future.

The purpose of this study was to systematically review the effect of interventional studies on kinesiophobia of PNE in persons with chronic pain and to analyze the effect size by performing a meta-analysis to: 1) Identify the characteristics of motor phobia of persons with chronic pain derived through the search process. 2) Analyzing the effect of PNE on kinesiophobia.

Methods

Study design

This study is a systematic review and meta-analysis study to integrate and analyze PNE studies conducted on persons experiencing MSP and chronic pain abroad.

The method of this study is presented in the protocol, and the protocol is registered in PROSPERO (registration: CRD42020215892).

Search strategy and selection of studies

Inclusion criteria

(1) Participants

Subjects were individuals with MSP, chronic pain excluding spinal disease, and those aged 19 years or older who received PNE.

(2) Intervention

Among the individuals with MSP excluding spinal diseases, the intervention of PNE among those with chronic pain was studied. PNE included neuroplasticity education, therapeutic neuroscience education, and neuroscience pain education interventions.

(3) Comparisons

The control group compared to PNE did not contain PNE. Completely different interventions were performed or compared with other educational programs. Also, in the case of a single group, it was compared with the pre-test value.

(4) Outcomes

The selection criterion was the quantitative value or the result description of the variable measured after education intervention was performed on persons with chronic pain who received PNE.

(5) Types of studies

We included randomized clinical trials (RCTs) involving PNE in individuals with chronic, MSP, excluding spinal disease.

Exclusion criteria

Studies that did not target persons with MSP, studies involving spinal disorders, and studies with biomedical education as an intervention were excluded.

Literature-search strategy

The content and method of this study were approved for exemption from the deliberation of the Institutional Review Board at Sahmyook University (IRB No. 2-1040781-A-N- 012020121HR).

Data was searched and collected in November 2020. The data was searched independently by two researchers (HK and SL) with experience in meta-analysis research. The search formula is constructed by merging terms representing chronic pain patients (P) and PNE (I).

The following electronic database was searched from record to October 2020: Pre-identified keywords (pain AND (Physiology OR Neuroscience OR Neurophysiology OR Biology) AND Education AND Chronic pain AND Randomized Controlled Trial) and the index terms were searched across all included databases (MEDLINE, EMBASE, CINAHL, PEDro and the Cochrane Central Register of controlled Trials).

Study selection and data extraction

First, documents searched through the database were removed from duplicate data in referencing software (EndNote X9, Thomson Reuters, NY, USA). Related theses were first checked through the theses titles and abstracts and then the original text of the selected theses were reviewed according to the selection criteria. In this process, the researchers explained the reasons for the excluded literature. General characteristics, intervention characteristics, and research results were extracted from the final selected study. The entire process of selecting and extracting the data was independently performed by two researchers. If the data did not match, the original text was reviewed together to make a final decision.

Quality assessment

For RCT studies, the 7-item Cochrane’s risk of bias (RoB) tool developed by The Cochrane Bias Method Group was used. To evaluate the quality of the study, two researchers with experience in meta-analysis studies evaluated the RoB as low (+), uncertain (?), and high (-), and then re-evaluated the unmatched items after reviewing the original text. Questions with different evaluations between researchers were agreed through discussions between researchers.

Strategy for data synthesis

The review was analyzed using RevMan 5.4 (The Cochrane Collaboration, Oxford, England). Meta-analysis was performed when there were the same outcome variables that could be analyzed or when there were quantitative values pre-test and post-test the outcome variables. Meta-analysis was performed when there were 3 or more studies by outcome variable. For the effect size, a standardized mean difference for the same outcome variable was selected as an analysis method, and a random effect model calculated that resets the weights in consideration of the variation between subjects of individual studies and the heterogeneity between each study [26]. The homogeneity of the selected studies was confirmed through Cochrane’s chi-square test and I2 test, and the I2 value of 0% indicated that there was no heterogeneity, 30%-60% meant moderate heterogeneity, and more than 75%, indicated that the heterogeneity is large [26]. When data was input, the standard deviation was calculated by the pooled standard deviation formula. Publication bias of the searched research papers was tested using a funnel plot [27].

Results

Literature search and characteristics of the included randomized clinical trials

Since there is no research conducted in Korea, a total of 303 articles were searched through international databases. Duplicate materials were excluded through the EndNote X9, resulting in 275 international publications. After that, according to the data selection and exclusion criteria, two researchers reviewed mainly the title and abstract, and since 230 articles were excluded because they did not meet the selection criteria, 43 studies were selected first. Two additional studies were selected through manual search, and 45 studies were reviewed in the original text.

Among them, 37 studies were not RCTs, pain and kinesiophobia were not included in the outcome variables, and chronic pain was not included. Therefore, 8 studies were finally selected. A total of 8 studies were analyzed by systematic review and meta-analysis (Figure 1).

Methodological quality evaluation of pain neuroscience education applied to chronic pain

For the quality evaluation, a pilot test was conducted and evaluated for three studies. The questionnaire ‘blind folded by the result evaluator’ required consensus among researchers, and the concordance rate of the subsequent evaluation was 100%. The methodological quality evaluation for 8 RCTs were as follows: random sequence generation (low: 7, high: 1), blinding of participants and personnel (low: 5, uncertain: 1, high: 2), blinding of outcome assessment (low: 5, uncertain: 2), and other biases (low: 8) (Figure 2).

Pain neuroscience education on kinesiophobia and pain for chronic pain patients

In this review, 8 RCTs were selected that included 369 patients with chronic pain. Each selected study included an additional type of intervention. The Tampa scale of kinesiophobia was used in selected studies to investigate the effect of PNE on kinesiophobia. In addition, Visual Analog Scale, Numeric Pain Rating Scale, Pressure Pain Threshold, Pain Disability Index, Pain Catastrophizing Scale were used in selected studies to investigate the effect on pain. All studies selected had a positive effect of PNE compared to the control except for only one study (Table 1) [28-35].

Methodological quality evaluation of pain neuroscience education applied to chronic pain

For quality evaluation, a pilot test was conducted and evaluated for three studies. The questionnaire ‘blind folded by the result evaluator’ required consensus among the researchers, and the concordance rate of the subsequent evaluation was 100%. The methodological quality evaluation for 8 RCTs were as follows: random sequence generation (+: 7, −: 1), blinding of participants and personnel (+: 5, ?: 1, −: 2), blinding of outcome assessment (+: 5, ?: 2), and other biases (+: 8).

Effectiveness of pain neuroscience education on kinesiophobia

In 369 patients with chronic pain, 8 RCTs evaluated kinesiophobia. Compared to the control group, the kinesiophobia was significantly improved. The results analyzed through the random-effect model showed significant heterogeneity (−0.86; 95% confidence interval [CI], −1.22 to −0.51; heterogeneity [χ2=21.18, df=7, I2=67%]) and significant overall effect (Z=4.80) (Figure 3).

Effectiveness of PNE on pain

In 369 patients with chronic pain, 8 RCTs evaluated pain. Compared to the control group, the pain was significantly improved. The results analyzed through the random-effect model showed significant heterogeneity (−0.53; 95% CI, −1.05 to −0.01; heterogeneity [χ2=47.42, df=7, I2=85%]) and significant overall effect (Z=2.01) (Figure 4).

Publication bias

As a result of visually checking the degree of symmetry through a funnel plot for the bias test, the study was evenly distributed even in areas that were not statistically significant, indicating that there was relatively no publication bias (Figure 5). As for the statistical significance of the degree of asymmetry, Egger’s regression test was not conducted because there were fewer than 10 studies included in the meta-analysis.

Discussion

This review was performed to confirm the effects of PNE on kinesiophobia and pain in persons with chronic pain. It

was found that PNE alone was more effective when combined with trigger point dry needling and manual therapy [28,36]. In addition, regardless of therapeutic intensity, a single session alone showed significant improvement [30,35], and indirect online education rather than direct education also showed significant improvement [29,34].

In patients with chronic pain, the function is affected by kinesiophobia and fear of pain in a persistant pain sequence even after treatment. Also, it can be said that the influence of the biopsychosocial focus was revealed rather than the biomedical focus, which was explained as part of educational treatment until recently. Expletively, it is a new approach to manage chronic pain in rehabilitation and clinical, and could be included in telerehabilitation tailored to COVID-19. In relation to telerehabilitation, studies that observe the effects through distance education, such as PNE through Youtube, is gradually in progress [31].

This review was conducted to determine the effects of PNE on kinesiophobia and pain compared to general interventions in chronic pain. The review did not take into account the type, intensity, or duration of the PNE protocol. In addition, only the results measured post intervention were used. In further studies, sub-analysis including similarity to combined interventions and classification according to follow-up period is considered necessary.

The implications of this study can be explained by dividing into qualitative and quantitative factors. Through the review of qualitative components, PNE should consider the method of delivery and the importance of the communicator because it is important to intervene with professional knowledge. Also, the implications through the quantitative evaluation were that PNE was effective in chronic pain by comparing it with other interventions so it could be combined with qualitative components to provide a more useful method.

Conflict of Interest

The authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article.

Figures
Fig. 1. PRISMA flow diagram of search and the study selection process.
Fig. 2. Risk of bias of the systematic review. (A) Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies, (B) risk of bias summary: review authors’ judgements about each risk of bias item for each included study.
Fig. 3. Forest plot of pain neuroscience education versus control in the post-intervention; primary outcome kinesiophobia. Std: standardized, CI: confidence interval, IV: weighted mean difference, A: random sequence generation, B: allocation concealment, C: blinding of participants and personnel, D: blinding of outcome assessment, E: incomplete outcome data, F: selective reporting.
Fig. 4. Forest plot of pain neuroscience education versus control in the post-intervention; secondary outcome pain. Std: standardized, CI: confidence interval, IV: weighted mean difference, A: random sequence generation, B: allocation concealment, C: blinding of participants and personnel, D: blinding of outcome assessment, E: incomplete outcome data, F: selective reporting.
Fig. 5. Funnel plots of standard error by standardized mean difference. (A) Kinesiophobia, (B) pain. SE: standard error, SMD: standardized mean difference.
Tables

Table 1

Characteristics of included studies

Study Sample size Participants Interventions Therapeutic intensity Control Outcome measures Authors conclusions Conuntry, setting
Valiente-Castrillo, et al. (2020) [28] 41 Chronic myofascial neck pain PNE+TrPDN Total intervention period: 2 weeks
EG: 6 sessions of DN (3 day/week), 3 sessions of PNE (30 minutes)
CG: 6 sessions of DN
TrPDN Kinesiophobia: TSK
Pain: VAS
The inclusion of PNE combined with DN resulted in greater improvements in kinesiophobia, pain anxiety, and pain-related beliefs Spain, Hospital Universitario Infanta Sofia
Malfliet, et al. (2018) [29] 94 Chronic spinal pain PNE+TCE
Cognition‐targeted, Biopsychosocial approach
Total intervention period: 12 weeks
EG: 3 sessions of PNE, 15 exercise sessions
CG: 3 sessions of BNE, 15 exercise sessions
BNE+PCE
Biomedical approach
Kinesiophobia: TSK
Pain: NPRS
PNE combined with CTMCTappears 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 Belgium, Vrije Universiteit Brussel
Meeus, et al. (2010) [30] 46 Chronic fatigue syndrome PPE Total intervention period: immediately
EG: 1 session (30 minutes)
CG: 1 session (30 minutes)
PSE Kinesiophobia: TSK
Pain: PPT
A 30-minute educational session on pain physiology imparts a better understanding of pain and brings about less rumination in the short term Belgium, University-based chronic fatigue clinic
Malfliet, et al. (2018) [31] 111 Chronic spinal pain Blended-learning PNE Total intervention period: 2 weeks
EG: 3 sessions of PNE (30 minutes to 1 hour)
CG: 3 sessions of BNE (30 minutes to 1 hour)
BNE Kinesiophobia: TSK
Pain: PDI
Blended-learning PNE was able to improve kinesiophobia and illness perceptions in participants with chronic spinal pain Belgium, University hospitals in Ghent and Brussels
Oosterwijck, et al. (2013) [32] 30 Fibromyalgia PPE Total intervention period: 2 weeks
EG: 2 sessions (30 minutes)
CG: 2 sessions (30 minutes)
AME Kinesiophobia: TSK
Pain: PCS
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 Belgium, Vrije Universiteit Brussel
Pardo, et al. (2018) [33] 56 Chronic low back pain PNPE+TE Total intervention period: 3 months
EG: 2 sessions of PNPE (30 to 50 minutes), TE (daily)
CG: TE (daily)
TE Kinesiophobia: TSK
Pain: NPRS
Combining PNE with TE resulted in significantly better results for participants with CLBP, with a large effect size, compared with TE alone Spain, Alcala’ University
Ryan, et al. (2010) [34] 34 Chronic low back pain PBE+EX Total intervention period: immediately
EG: 1 sessions of PBE (2 hours 30 minutes), EX (1 day/week, 30-55 minutes)
CG: 1 sessions of PBE (2 hours 30 minutes)
PBE Kinesiophobia: TSK
Pain: NPRS
In the short term, pain biology education alone was more effective for pain and pain self-efficacy than a combination of pain biology education and group exercise classes UK, Glasgow Caledonian University
Saracoglu et al. (2020) [35] 57 Chronic low back pain PNE+MT+HEP Total intervention period: 4 weeks
EG: MT (2 day/week, 30 minutes), PNE (each week, 40-45 minutes), HEP (3 day/week, 10 repetitions)
CG: MT (2 day/week, 30 minutes), HEP (3 day/week, 10 repetitions)
MT+HEP Kinesiophobia: TSK
Pain: NPRS
Multimodal treatment program combining PNE, MT, and HEP is an effective method for improving back performance and reducing pain, disability, and kinesiophobia in the short (4 weeks) and midterm (12 weeks) Turkey, Kutahya Health Sciences University Hospital

AME: activity management education, BNE: back and neck education, CG: control group, CLBP: chronic low back pain, CTMCT: cognition-targeted motor control training, DN: dry needling, EG: experimental group, EX: exercise, FM: fibromyalgia, HEP: home exercise therapy, NPRS: numeric pain rating scale, MT: manual therapy, PBE: pain biology education, PCE: pain- contingent exercise, PCS: pain catastrophizing scale, PDI: pain disability index, PNE: pain neuroscience education, PNPE: pain neurophysiology education, PPE: pain physiology education, PPT: pressure pain threshold, PSE: pacing and self-management education, RE: relaxation education, TCE: time-contingent exercise, TE: therapeutic exercise, TrPDN: trigger point dry needling, TSK: tempa scale, VAS: visual analog scale.



 

Full Text(PDF) Free

Cited By Articles
  • CrossRef (0)
  • Authorship and ethical issues