Pain neuroscience education is currently one of the techniques being explored in physiotherapy for pain management. The benefits of this technique are gradually becoming evident in various published studies. So far, it has been widely studied for its short-term effects, but the education provided has typically been generic, not focused on exercise. However, it is suggested that this technique should be combined with exercise to achieve the expected outcomes. Therefore, pain education should be tailored to the specific physical activities the subject will perform to maximise its effectiveness. The primary aim of this study is to analyse the outcome of combining exercise with tailored pain neuroscience education on aspects such as pain, kinesiophobia, catastrophizing, exercise conceptualization, and upper limb function in subjects with neck pain. The secondary aim is to evaluate the relationship between kinesiophobia and catastrophizing and their impact on the results of various upper limb performance tests. Finally, the effects of therapeutic exercise alone will be compared with those of therapeutic exercise combined with pain neuroscience education, focusing on pain, kinesiophobia, catastrophizing, and exercise conceptualization. A double-blind, randomised clinical trial has been designed, in which three intervention protocols will be applied to 81 subjects with non-specific neck pain: education with exercise, exercise alone, and placebo alone. Subjects with non-specific neck pain who meet the inclusion criteria will be enrolled. Demographic characteristics of the subjects, as well as pain, kinesiophobia, catastrophizing, and upper limb performance test scores, will be assessed. This study aims to explore the potential relevance of a pain neuroscience education session prior to therapeutic exercise, as well as to influence the clinical recommendations made by clinicians during treatment.
In recent years, education in pain neuroscience has been shown to have a positive impact on pain subjects. However, the education provided is often generic and not adapted to exercise, although it is recommended that this therapy should be combined with exercise. Therefore, the aim of this study is to assess the results of the combination of exercise and pain neuroscience education focused on the exercise to be performed by subjects in pain or kinesiophobia. Therefore, the main objective of the study is to evaluate the effects of pain neuroscience education in non-specific neck pain on pain intensity, kinesiophobia, catastrophizing, exercise conceptualization and upper limb functionality itself in subjects with non-specific neck pain. The specific objective is to compare the effect of therapeutic exercise alone with the effect of therapeutic exercise in combination with pain neuroscience education on pain, kinesiophobia, catastrophizing and exercise conceptualization. Similarly, the aim is to determine the relationship between kinesiophobia and catastrophism and the results obtained in upper limb performance tests. For this purpose, the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST), the Seated Medicine Ball Throw test (SMBT) and the Single Arm Military Press (SAMP) have been chosen, the first two of which have not been studied in patients with non-specific neck pain to date. This study aims to have an impact on the possible relevance of a pain neuroscience education session prior to therapeutic exercise, as well as on the clinical recommendations made by healthcare professionals during treatment. DESIGN The study consists of a randomised, double-blind clinical trial. Subjects will be randomised into 3 groups: control group, where subjects will receive a placebo (TENS off, in this case); intervention group 1, where pain neuroscience education (PNE) and exercise will be applied; and intervention group 2, to which only exercise will be applied. The allocation will be blinded to the subject and to one of the two investigators. SELECTION CRITERIA Inclusion criteria: o Adults aged between 18 and 65 years. o Subjects with non-specific neck pain at the time of the intervention reaching at least a 3 on the Numerical Pain Rating Scale (NPRS scale). Exclusion criteria: o Pregnancy o Severe illnesses: diabetes, cancer, neurological, depression, etc... o Cognitive disorders or illnesses. o Subjects who have received physiotherapy treatment in the last month. o Subjects who are receiving concomitant physiotherapy treatment for this pathology. o Subjects with specific neck pain, such as any traumatic pathology, whiplash or with a diagnosis associated with neurological compromise or peripheral nerve damage. o Physiotherapy students or professional physiotherapists. Subjects included in the study must complete the informed consent form, meet the inclusion criteria and not meet the exclusion criteria. Prior to any type of procedure, subjects will be informed about the study and about their right to discontinue their participation and/or request the withdrawal of their data at any time. DESCRIPTION OF THE PROCEDURE At the beginning, all subjects will sign the informed consent form, demographic data will be recorded by means of an interview and a questionnaire specifically designed for the work. After that, baseline measurements of outcome variables will be taken. Fear of movement and kinesiophobia will be measured with the Tampa Scale of Kinesiophobia (TSK- 11SV), pain catastrophizing with the Pain and Catastrophizing Scale (PCS), and subject's beliefs about pain with the Pain Beliefs Questionnaire (PBQ). The Spanish validated versions of all the aforementioned scales will be used. The Numerical Pain Rating Scale (NPRS) will be used to assess subjects' current pain and spontaneous or evoked pain intensity. Researcher A will then show each subject images of the 3 performance tests they will have to perform, as well as provide an explanation of their execution: Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST), Single Arm Military Press (SAMP) and Seated Medicine Ball Throw Test (SMBT). Regardless of whether subjects are later assigned to the exercise group or not. These tests are among the most widely used tests to measure upper limb function, although they have not been studied in subjects with non-specific neck pain. The Single Arm Military Press (SAMP) test is the only performance-based measure of upper limb disability that was designed specifically for subjects with neck pain. All these tests involve active movements that could be conditioned by the subject's pain and beliefs related to kinesiophobia, so they could be of great use to observe whether an educational approach decreases upper limb dysfunction. Finally, subjects' beliefs about the exercises explained in relation to their pathology will be assessed by means of a questionnaire specifically designed for this purpose. After this procedure is completed by all participants, they will be randomised into three groups, using a randomisation website (Research Randomizer, n.d.) and will undergo a physiotherapy session that includes different approaches for each group. In the PNE and exercise group the investigator will proceed with pain neuroscience education focused on concepts related to movement-related fear and the benefits of exercise for 20 minutes. Specifically, the exercises presented in the generic part of the procedure will be discussed. To assess whether the education has resulted in changes to the subjects' beliefs, they will be reassessed regarding their beliefs about the exercises in relation to their neck pain following the education session. Afterward, subjects will complete psychosocial scales and rate their pain and evoked pain at that moment independently, without the need for the researcher to be present, in order to ensure blinding. Subsequently, the subject will undergo the performance tests in a randomised order (Closed Kinetic Chain Upper Extremity Stability Test, Single Arm Military Press, and Seated Medicine Ball Throw), which will be conducted by a second investigator who is unaware of whether the subject has received education. The exercise intervention will then proceed using variations of the performance tests, also carried out by the second investigator. Specifically, the load or execution time will be increased until the participant reports a perceived fatigue of 4-6 (moderate to strong) on the modified Borg scale. Finally, the participant will autonomously complete the scales, rate their pain and exercise-related questions for the final time. The exercise group does not include pain neuroscience education. Following the initial assessment, the subject will be left alone for 20 minutes with instructions to think about the exercises but not to perform them. Afterward, subjects will complete psychosocial scales and will rate their pain and evoked pain at that moment independently, without the need for the researcher to be present, in order to ensure blinding. Subsequently, the subject will undergo the performance tests in a randomised order (Closed Kinetic Chain Upper Extremity Stability Test, Single Arm Military Press, and Seated Medicine Ball Throw), which will be conducted by a second investigator who is unaware of whether the subject has received education. The exercise intervention will then proceed using variations of the performance tests, also carried out by the second investigator. Specifically, the load or execution time will be increased until the participant reports a perceived fatigue of 4-6 (moderate to strong) on the modified Borg scale. Finally, the participant will independently complete the scales, rate their pain, evoked pain, and exercise-related questions one final time. The control group does not receive pain neuroscience education or exercise. Following the initial assessment, the subject will be left alone for 20 minutes with instructions to think about the exercises but not to perform them. Afterward, subjects will independently complete psychosocial scales and will rate their pain and evoked pain at that moment, without the need for the researcher to be present, in order to ensure blinding. Subsequently, participants in this group will receive a placebo intervention administered by a second investigator. A TENS device will be placed on them and kept turned off for 15 minutes. subjects will be informed that the device is operating at a very low intensity, too weak to be perceived. Additionally, performance tests will not be assessed in this group. Finally, the participant will autonomously complete the scales, rate their pain and exercise-related questions for the final time. Therefore, all groups will be assessed 3 times during the session. The first time they will be accompanied by the first investigator, who will answer any questions that may arise. The second and third time the subject will do it autonomously, unaccompanied by any researcher, to avoid bias.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
DOUBLE
Enrollment
81
The intervention consists of 20 minutes of pain neuroscience education, focused on concepts related to movement-related fear and the benefits of exercise for managing pain. Specific exercises, mentioned in the generic part of the procedure, will be discussed during this session. This intervention aims to modify the subjects' beliefs regarding exercises and their neck pain.
The exercise intervention includes performance tests and variations of these tests used as exercises, such as the Closed Kinetic Chain Upper Extremity Stability Test, Single Arm Military Press, and Seated Medicine Ball Throw. Variations of these performance tests will be implemented, with adjustments made to the load or execution time until the participant reports a perceived fatigue of 4-6 (moderate to strong) on the modified Borg scale.
The placebo intervention involves the application of a TENS device, which will be placed on the participant and kept turned off for 15 minutes. Subjects will be informed that the device is working at a very low intensity, too weak to be perceived. This intervention aims to simulate the experience of treatment without delivering any therapeutic effect.
Clínica de Franscisco Ortega Rehabilitación Avanzada S.L.
Elche, Alicante, Spain
RECRUITINGChange in Kinesiophobia Level from Baseline to the End of the Interventions as Assessed by the Tampa Scale for Kinesiophobia (TSK-11SV)
The level of kinesiophobia will be assessed using the Tampa Scale for Kinesiophobia (TSK-11SV). This scale evaluates kinesiophobia (fear of movement) through 11 statements, which participants must rate on a Likert scale from 1 to 4, where 1 indicates strongly disagree and 4 indicates strongly agree. Higher scores reflect greater kinesiophobia (minimum score: 11; maximum score: 44). The validated Spanish version of the scale will be used.
Time frame: Baseline (Day 1), post-education/rest (Day 1), and post-intervention (Day 1).
Change in Pain Beliefs from Baseline to the End of the Interventions as Assessed by the Pain Beliefs Questionnaire (PBQ).
Pain beliefs will be assessed using the Pain Beliefs Questionnaire (PBQ), which evaluates beliefs regarding the causes, consequences, and necessary treatment of pain. The questionnaire is divided into two subscales: "organic" and "psychological." It consists of 12 items, with 8 items belonging to the "organic" subscale and 4 to the "psychological" subscale. The PBQ uses a 6-point Likert scale ranging from "Always" to "Never," corresponding to scores of 6 and 1, respectively. Higher scores on each subscale indicate that the respondent considers the corresponding pain-related beliefs to be of greater importance.
Time frame: Baseline (Day 1), post-education/rest (Day 1), and post-intervention (Day 1).
Change in Catastrophizing Level from Baseline to the End of the Interventions as Assessed by the Pain and Catastrophizing Scale (PCS).
The level of catastrophizing will be assessed using the Pain and Catastrophizing Scale (PCS). This scale evaluates catastrophizing in response to pain and the negative and exaggerated perception of the painful experience. It consists of 13 statements describing different thoughts and feelings that may be associated with pain. The participant is required to indicate the extent to which they experience these thoughts and feelings when they are in pain. Each statement is rated on a Likert scale from 0 to 4, where 0 means "not at all" and 4 means "all the time." Higher scores indicate a higher degree of catastrophizing. The validated Spanish version of the scale will be used.
Time frame: Baseline (Day 1), post-education/rest (Day 1), and post-intervention (Day 1).
Change in Pain Intensity from Baseline to the End of the Interventions as Assessed by the Numerical Pain Rating Scale (NPRS).
Pain intensity will be assessed using the Numerical Pain Rating Scale (NPRS). This scale evaluates the intensity of pain experienced by the participant, using a 10-point scale, where 0 represents no pain and 10 represents the maximum possible pain. Higher scores correspond to greater pain intensity.
Time frame: Baseline (Day 1), post-education/rest (Day 1), and post-intervention (Day 1).
Change in Evoked Pain Intensity from Baseline to the End of the Interventions as Assessed by the Numerical Pain Rating Scale (NPRS)
Evoked pain will be assessed using the Numerical Pain Rating Scale (NPRS). Participants will be asked to perform a movement that evokes pain related to their condition. Pain intensity will then be evaluated on a 10-point scale, where 0 represents no pain and 10 represents the maximum possible pain. Higher scores correspond to greater pain intensity.
Time frame: Baseline (Day 1), post-education/rest (Day 1), and post-intervention (Day 1).
Demographic data
Participants will complete a demographic questionnaire, including descriptive variables such as age, sex, weight, height, level of physical activity, comorbidities, duration of pain, side of pain, and smoking status.
Time frame: Baseline (Day 1).
Change in Beliefs About Specific Exercises from Baseline to the End of the Interventions as Assessed by the Custom Questionnaire on Beliefs About Specific Exercises.
Beliefs about specific exercises in relation to pain will be assessed using a custom questionnaire. The questionnaire evaluates the participants' beliefs regarding the specific exercises they will perform. Participants will first be shown photographs of the exercises they are required to do, and then they will respond to the questionnaire by selecting a number on a visual analogue scale from 1 to 10, where 1 indicates "strongly disagree" and 10 indicates "strongly agree." Higher scores reflect stronger beliefs about the exercises in relation to their pain. This questionnaire was specifically designed for this study and is being used for data collection.
Time frame: Baseline (Day 1), post-education/rest (Day 1), and post-intervention (Day 1).
Average pain intensity over the last 7 days as assessed by the numerical pain rating scale (NPRS)
Average pain intensity over the last 7 days will be assessed using the Numerical Pain Rating Scale (NPRS). This scale evaluates both the average pain intensity experienced by the participant over the last 7 days, using a 10-point scale where 0 represents no pain and 10 represents the maximum possible pain. Higher scores correspond to greater pain intensity.
Time frame: Baseline (Day 1).
Worst Pain Intensity in the Last 7 Days as Assessed by the Numerical Pain Rating Scale (NPRS)
The worst pain intensity over the last 7 days will be assessed using the Numerical Pain Rating Scale (NPRS). This scale evaluates the worst pain intensity experienced by the participant over the past 7 days, using a 10-point scale where 0 represents no pain and 10 represents the maximum possible pain. Higher scores indicate greater pain intensity.
Time frame: Baseline (Day 1).
Functional Performance of the Upper Extremity as Assessed by the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST)
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Functional performance of the upper extremities will be assessed using the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST), a test designed to evaluate upper limb stability and control. During the test, male participants will adopt a push-up position, while female participants will assume a modified push-up position (knees on the ground). Both hands will be placed on two strips on the floor at the same height, with a distance of 91.4 cm between them. In these positions, participants will be required to move one hand to touch the back of the opposite hand, then return to the starting position, repeating the movement with the other hand, for 15 seconds. The test will be performed for three 15-second repetitions at maximum effort, with a 45-second rest between each repetition. The outcome measure will be the average number of touches (mean of the number of touches from the three attempts).
Time frame: Post-education/rest (Day 1).
Functional Performance of the Upper Extremity as Assessed by the Single Arm Military Press test (SAMP test)
Functional performance of the upper extremity will be assessed using the Single Arm Military Press (SAMP). This performance-based measure is designed to assess upper extremity strength during an overhead activity, aimed at differentiating between healthy individuals and those with varying levels of nonspecific neck pain and upper extremity disability. The exercise is performed with participants standing, with their feet shoulder-width apart, holding a 1 kg dumbbell at shoulder height with their dominant hand. Participants are instructed to lift the dumbbell overhead, performing a full shoulder flexion and elbow extension. The test consists of repeating this motion as quickly as possible for 30 seconds with maximal effort. The SAMP score is determined by counting the number of correct repetitions completed in 30 seconds. The test is stopped if the participant is unable to complete another correct repetition.
Time frame: Post-education/rest (Day 1).
Functional Performance of the Upper Extremities as Assessed by the Seated Medicine Ball Throw Test (SMBT)
Functional performance of the upper extremities will be assessed using the Seated Medicine Ball Throw Test (SMBT). Participants will sit with their back against the wall, legs extended, holding a 2 kg medicine ball with arms at 90° shoulder abduction and elbows flexed at chest height. They will throw the ball forward as far as possible without losing contact with the wall. The distance will be measured by a tape placed 10 meters from the subject's starting point. Three maximum effort throws will be performed with 1-minute rests between each, and the result will be the average of the three throws.
Time frame: Post-education/rest (Day 1).