Effect of neuroscience education on subjects with chronic knee pain related to osteoarthritis: a randomized controlled trial

In this PhD study, the evidence for the role of central pain mechanisms in people with OA was investigated by means of a narrative and a systematic review of the existent literature. In addition, clinical criteria for recognizing central sensitization in subjects with knee OA are discussed as well as the rationale for a comprehensive integrative treatment program including pain neuroscience education and manual therapy for this population. Clinicians may find some practical problems when combining biomechanical approaches with more brain targeted approaches in a clinical setting, especially in a specific population like OA, where patients are often a bit older and tend to stick with pure biomechanical illness perceptions in line with the earlier understanding of OA. In this PhD dissertation, the rationale and tips and tricks to target the brain without ignoring the joints in patients with knee OA has been first provided in a narrative paper and afterwards tested by means of a randomized controlled trial. General conclusions achieved after this Doctoral Thesis are: -Substantial scientific evidence indicates a role for central sensitization in osteoarthritis pain including those with knee osteoarthritis, yet it is necessary to develop strategies to allow reliable and systematic recognition of patients with osteoarthritis whose pain has a (predominant) central sensitization component. -Optimum treatment for people with knee osteoarthritis pain requires a biopsychosocial approach and determination of how peripheral and central factors are contributing to pain in each patient in order to enable individualization of treatment strategies. Physical therapists are well positioned to deliver an individualized intervention because they are cognizant of the need for a biopsychosocial approach to management. -The area of pain reported by individuals with knee osteoarthritis pain is associated with some measures of central sensitization. Clinicians should be attentive for individuals with knee osteoarthritis showing extended areas of pain as this may be an indicator of altered nociceptive processing mechanisms. Pain drawings may constitute an easy and cheap way for the early identification of central sensitization in people with knee osteoarthritis pain. -Sound scientific rationale and practical guidelines have been developed for the application of a combined manual therapy and pain neuroscience education approach in patients with chronic osteoarthritis-related pain and central sensitization as their dominant pain mechanism. -In subjects with knee osteoarthritis waiting for knee joint replacement, pre-operative pain neuroscience education combined with knee joint mobilization did not produce any additional benefits over time in knee pain and disability and central sensitization measures compared with biomedical education with knee joint mobilization. Superior effects in the pain neuroscience education with knee joint mobilization group were only observed for psychosocial variables related to pain catastrophizing and kinesiophobia.In this PhD study, the evidence for the role of central pain mechanisms in people with OA was investigated by means of a narrative and a systematic review of the existent literature. In addition, clinical criteria for recognizing central sensitization in subjects with knee OA are discussed as well as the rationale for a comprehensive integrative treatment program including pain neuroscience education and manual therapy for this population. Clinicians may find some practical problems when combining biomechanical approaches with more brain targeted approaches in a clinical setting, especially in a specific population like OA, where patients are often a bit older and tend to stick with pure biomechanical illness perceptions in line with the earlier understanding of OA. In this PhD dissertation, the rationale and tips and tricks to target the brain without ignoring the joints in patients with knee OA has been first provided in a narrative paper and afterwards tested by means of a randomized controlled trial. General conclusions achieved after this Doctoral Thesis are: -Substantial scientific evidence indicates a role for central sensitization in osteoarthritis pain including those with knee osteoarthritis, yet it is necessary to develop strategies to allow reliable and systematic recognition of patients with osteoarthritis whose pain has a (predominant) central sensitization component. -Optimum treatment for people with knee osteoarthritis pain requires a biopsychosocial approach and determination of how peripheral and central factors are contributing to pain in each patient in order to enable individualization of treatment strategies. Physical therapists are well positioned to deliver an individualized intervention because they are cognizant of the need for a biopsychosocial approach to management. -The area of pain reported by individuals with knee osteoarthritis pain is associated with some measures of central sensitization. Clinicians should be attentive for individuals with knee osteoarthritis showing extended areas of pain as this may be an indicator of altered nociceptive processing mechanisms. Pain drawings may constitute an easy and cheap way for the early identification of central sensitization in people with knee osteoarthritis pain. -Sound scientific rationale and practical guidelines have been developed for the application of a combined manual therapy and pain neuroscience education approach in patients with chronic osteoarthritis-related pain and central sensitization as their dominant pain mechanism. -In subjects with knee osteoarthritis waiting for knee joint replacement, pre-operative pain neuroscience education combined with knee joint mobilization did not produce any additional benefits over time in knee pain and disability and central sensitization measures compared with biomedical education with knee joint mobilization. Superior effects in the pain neuroscience education with knee joint mobilization group were only observed for psychosocial variables related to pain catastrophizing and kinesiophobia

Author Response

In conclusion, it is key for physical therapists to acknowledge that an important subgroup of patients with OA develop hyperexcitability of the central nervous system and that CS plays a crucial role in the pain reported by these patients. Recent studies published in wellrespected journals support our argument

Pain Treatment for patients with osteoarthritis and central sensitization

Osteoarthritis is one of the most frequent, disabling, and costly pathologies of modern society. Among the main aims of osteoarthritis management are pain control and functional ability improvement. The exact cause of osteoarthritis pain remains unclear. In addition to the pathological changes in articular structures, changes in central pain processing or central sensitization appear to be involved in osteoarthritis pain. The latter calls for a broader approach to the management of patients with osteoarthritis. Yet, the scientific literature offers scant information addressing the treatment of central sensitization, specifically in patients with osteoarthritis. Inter-ventions such as cognitive-behavioral therapy and neuroscience education potentially target cognitive-emotional sensitization (and descending facilitation), and centrally acting drugs and exercise therapy can improve endogenous analgesia (descending inhibition) in patients with osteoarthritis. Future studies should assess these new treatment avenues

Fisioterapia del dolor miofascial y de la fibromialgia

114 páginasExiste una gran variedad de problemas de los tejidos blandos que son claramente reconocibles: efectos de traumatismos, procesos inflamatorios, debilidad, etc. El síndrome de dolor miofascial es una entidad extraordinariamente frecuente, diferente de las anteriores, pero, hasta la fecha, mal comprendida y escasamente difundida. En este libro tratamos de recoger tanto los síntomas como la importancia en el diagnóstico y su posible tratamiento

Effectiveness of a physical therapeutic exercise programme for caregivers of dependent patients: a pragmatic randomised controlled trial from Spanish primary care

Producción CientíficaFemale family caregivers (FFCs) constitute one of the basic supports of socio-health care for dependence in developed countries. The care provided by FFCs may impact their physical and mental health, negatively affecting their quality of life. In order to alleviate the consequences of providing care on FFCs, the Spanish Public Health System has developed the family caregiver care programme (FCCP) to be applied in primary care (PC) centres. The effectiveness of this programme is limited. To date, the addition of a physical therapeutic exercise (PTE) programme to FCCP has not been evaluated. A randomised multicentre clinical trial was carried out in two PC centres of the Spanish Public Health System. In total, 68 FFCs were recruited. The experimental group (EG) performed the usual FCCP (4 sessions, 6 h) added to a PTE programme (36 sessions in 12 weeks) whereas the control group performed the usual FCCP performed in PC. The experimental treatment improved quality of life (d = 1.17 in physical component summary), subjective burden (d = 2.38), anxiety (d = 1.52), depression (d = 1.37) and health-related physical condition (d = 2.44 in endurance). Differences between the groups (p < 0.05) were clinically relevant in favour of the EG. The experimental treatment generates high levels of satisfaction.Ministerio de Economía, Industria y Competitividad - (Project MTM2017–86061-C2–1-P)Junta de Castilla y León y Fondo Europeo de Desarrollo Regional (FEDER) - (Projects VA005P17 y VA002G18

The Spatial Extent of Pain Is Associated with Pain Intensity, Catastrophizing and Some Measures of Central Sensitization in People with Frozen Shoulder

The aim of this cross-sectional study was to explore the spatial extent of pain and its association with clinical symptoms, psychological features, and pain sensitization in people with frozen shoulder (FS). Forty-eight individuals with FS completed pain drawings (PDs) and reported their clinical symptoms including pain intensity (Visual Analogue Scale) and shoulder disability (Shoulder Pain and Disability Index). Moreover, pain sensitization measurements (pressure pain thresholds, temporal summation, conditioned pain modulation, and Central Sensitization Inventory (CSI)) were assessed. Psychological features were assessed by Pain Catastrophizing Scale (PCS) and Pain Vigilance and Awareness Questionnaire. Pain frequency maps were generated, Margolis rating scale was used for pain location, and Spearman correlation coefficients were computed. The mean (SD) pain extent was 12.5% (6.7%) and the most common painful area was the anterolateral shoulder region (100%). Women presented a more widespread pain distribution compared with men. Significant positive associations were obtained between pain extent and current pain intensity (rs = 0.421, p < 0.01), PCS (rs = 0.307, p < 0.05) and CSI (rs = 0.358, p < 0.05). The anterolateral region of the shoulder was the most common painful area in people with FS. Women with FS presented more extended areas of pain; and a more widespread distribution of pain was correlated with higher levels of pain, pain catastrophizing and pain sensitization

A Central Nervous System Focused Treatment Program for People with Frozen Shoulder: A Feasibility Study

Background: Frozen shoulder (FS) is a highly disabling pathology of poorly understood etiology, which is characterized by the presence of intense pain and progressive loss of range of motion (ROM). The aim of this study is to evaluate the feasibility and clinical impact of a CNS-focused treatment program for people with FS. Methods: 10 subjects with primary FS received a 10-week CNS-focused intervention including sensory discrimination training and graded motor imagery techniques delivered as clinic sessions (60 min) and home therapy (30 min five times per week). Measurements were taken at baseline, after a 2-week 'washout' period, after treatment, and at three months followup. The Shoulder Pain and Disability Index (SPADI) was the primary outcome. Secondary measures were feasibility-related outcomes, self-reported shoulder pain, active and passive range of motion, two-point discrimination threshold (TPDT), left/right judgement task (LRJT), fear-avoidance (Tampa Scale for Kinesiophobia), pain catastrophization (Pain Catastrophizing Scale), and pain sensitization (Central Sensitization Inventory). A Student's t-test was used to assess the 'washout' period. A repeated measure analysis of variance (ANOVA) was used to evaluate within-subjects' differences for all outcome measures in the different assessment periods and a pairwise analysis was used to compare between the different assessment points. Statistical significance was set at p < 0.05. Results: 70% of participants completed the treatment. No significant changes were found after 'washout' period except for TPDT (p = 0.02) and SPADI (p = 0.025). Improvements in self-reported shoulder pain (p = 0.028) and active shoulder flexion (p = 0.016) were shown after treatment (p = 0.028) and follow-up (p = 0.001) and in SPADI at follow-up (p = 0.008). No significant changes were observed in TPDT, LRJT, fear-avoidance, pain catastrophization, and pain sensitization. Conclusions: a CNS-focused treatment program might be a suitable approach to improve pain and disability in FS, but further research is needed to draw firm conclusions