Pain Neuroscience Education and Physical Therapeutic Exercise for Patients with Chronic Spinal Pain in Spanish Physiotherapy Primary Care: A Pragmatic Randomized Controlled Trial

Abstract

Chronic musculoskeletal pain affects more than 20% of the population, leading to high health care overload and huge spending. The prevalence is increasing and negatively affects both physical and mental health, being one of the leading causes of disability. The most common location is the spine. Most treatments used in the Public Health Services are passive (pharmacological and invasive) and do not comply with current clinical guidelines, which recommend treating pain in primary care (PC) with education and exercise as the first-line treatments. A randomized multicentre clinical trial has been carried out in 12 PC centres. The experimental group (EG) conducted a program of pain neuroscience education (6 sessions, 10 h) and group physical exercise with playful, dual-tasking, and socialization-promoting components (18 sessions in 6 weeks, 18 h), and the control group performed the usual physiotherapy care performed in PC. The experimental treatment improved quality of life (d = 1.8 in physical component summary), catastrophism (d = 1.7), kinesiophobia (d = 1.8), central sensitization (d = 1.4), disability (d = 1.4), pain intensity (d = 3.3), and pressure pain thresholds (d = 2). Differences between the groups (p < 0.001) were clinically relevant in favour of the EG. Improvements post-intervention (week 11) were maintained at six months. The experimental treatment generates high levels of satisfaction.

Keywords: chronic pain; chronic spinal pain; pain neuroscience education; physical exercise; primary care; randomized controlled trial.

Figure A1

Pragmatic Explanatory Continuum Indicator Summary-2 (PRECIS-2) wheel for this pragmatic trial. For each domain higher scores indicate a more pragmatic approach and lower scores a more explanatory approach.

Figure 1

Distribution of the program followed by the experimental group.

Figure 2

CONSORT flow diagram. * Initial assessment included initial personal and sociodemographic variables, health-related quality of life (SF-36), catastrophism (PCS: pain catastrophizing scale), kinesiophobia (TSK-11: Tampa Scale for Kinesiophobia-11), central sensitization (CSI: central sensitization inventory), disability (RMDQ: Roland–Morris disability questionnaire), pain intensity (VAS: visual analogue scale), pain areas (McGill maps), and algometry (PPTs: pain pressure thresholds). ^† Post-intervention assessment satisfaction survey with healthcare received (CSQ-8: client satisfaction questionnaire-8) was added. ^‡ The 6-month assessment was the same as the initial assessment.

Figure 3

Outcome graphical representation. This figure contains outcomes graphical representation in boxplot. Green colour represent experimental group (EG) and red colour represent control group (CG). First boxplot represents the initial assessment, the second boxplot represents post-intervention assessment and the third the assessment at six months; (A) Boxplot for physical component summary (PCS); (B) Boxplot for mental component summary (MCS); (C) Boxplot for catastrophism outcomes; (D) Boxplot for kinesiophobia outcomes (TSK-11); (E) Boxplot for CSI scores (part A); (F) Boxplot for disability (RMDQ); (G) Boxplot for intensity of pain (VAS; (H) boxplot for PPT outcomes; EG d = X.X: Experimental Group effect size at six months (Cohen’s d); CG d = X.X: Control group effect size at six months. Hollow circles represents outlier values.