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.
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).
(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 criteriaStudies that did not target persons with MSP, studies involving spinal disorders, and studies with biomedical education as an intervention were excluded.
Literature-search strategyThe 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 extractionFirst, 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 assessmentFor 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.
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].
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).
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).
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].
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).
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).
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).
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.
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.
The authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article.
Characteristics of included studies
Study | Sample size | Participants | Interventions | Therapeutic intensity | Control | Outcome measures | Authors conclusions | Conuntry, setting |
---|---|---|---|---|---|---|---|---|
Valiente-Castrillo, |
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, |
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, |
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, |
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, |
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, |
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, |
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.