OBJECTIVE: To investigate the effects of adding pain science or ergonomics messages to guideline advice on feelings of reassurance and management intentions among people with acute low back pain (LBP). DESIGN: Three-arm parallel-group randomized experiment. METHODS: We recruited people with acute LBP (pain for ≤6 weeks) to participate in an online experiment. Participants were randomized at a 1:1:1 ratio to one of three groups: guideline advice alone or guideline advice with the addition of brief pain science or ergonomics messages. The intervention was delivered via prerecorded videos in all 3 groups. Coprimary outcomes were reassurance that (1) no serious condition is causing LBP and (2) continuing with daily activities is safe. Secondary outcomes were perceived risk of developing chronic pain, management intentions (bed rest, see a health professional, see a specialist, and imaging), credibility, and relevance of the advice in addressing the participant\'s concerns. RESULTS: Two thousand two hundred ninety-seven responses (99.3% of 2,313 randomized) were analyzed. Adding brief pain science or ergonomics messages to guideline advice did not change reassurance that LBP was not caused by serious disease. The addition of ergonomics advice provided worse reassurance that it is safe to continue with daily activities compared to guideline advice (mean difference [MD], -0.33; 95% CI: 0.13, 0.53). There was no difference between groups on management intentions. CONCLUSION: Adding pain science or ergonomics messages to guideline advice did not increase reassurance or change management intentions in people with acute LBP. Ergonomics messages may lead to reduced feelings of reassurance. J Orthop Sports Phys Ther 2023;53(12)1-11. Epub 26 September 2023. doi:10.2519/jospt.2023.12090.

UNASSIGNED: Chronic pain and pain catastrophization are growing problems across the United States, within the Hispanic-American population. Pain neuroscience education (PNE) changes pain knowledge and beliefs in many populations, but its impact on reconceptualization in people of Hispanic-American origin is unknown.
UNASSIGNED: Explore the changes in pain knowledge in Hispanic-American individuals and the process involved in reconceptualization following a PNE lecture.
UNASSIGNED: Eight Hispanic-American adults participated in a mixed-methods exploratory study. The Revised Neurophysiology of Pain Questionnaire (R-NPQ) was completed before, immediately after, and eight months after an adapted PNE lecture. A focus group involving four participants discussed the impact of PNE. Transcripts were translated and theme coded, and a concept map was developed by consensus.
UNASSIGNED: R-NPQ scores improved from 25.3% to 43.5% post-lecture, and the number of unsure responses decreased from 41.5% to 18.4%. At eight months, R-NPQ scores remained stable (44.2%) but unsure responses increased (28.9%). Themes that contributed to the process of change included cognitive dissonance, relevance of instruction, idea exchange through peer interaction, reflection, confidence, changed behaviors, and educational utility.
UNASSIGNED: While small improvements in knowledge and perception of pain appeared to occur with the PNE, knowledge remained low. Consideration of adult learning principles such as applicability, peer-interaction, the confrontation of beliefs, and reflection throughout PNE may enhance its impact. Future investigation should explore the efficacy of this intervention, when compared or combined with other techniques in the treatment of Hispanic-Americans experiencing persistent pain.

To explore how Australian exercise physiologists (EPs) utilise pain neuroscience education (PNE) in their management of patients with knee osteoarthritis.
A semi-structured interview concerning a knee osteoarthritis vignette was designed to understand each participant\'s beliefs about physical activity, pain, injury and coping strategies and quantify their use of pain neuroscience concepts. Themes were derived from pre-determined pain target concepts as well as others that emerged from thematic analysis.
Thirty EPs (57% male, mean clinical experience 7 years (SD 7.1) participated in the semi-structured interviews. 13 themes emerged. EPs primarily focussed on: (1) active treatment strategies are better than passive, (2) pain and tissue damage rarely relate, and (3) learning about pain can help individuals and society. Other themes included the use of biomedical-based education, pain during exercise and delivery of PNE. Underutilised themes included the role of the brain in pain, validation that pain is real and personal, the concept of danger sensors as opposed to pain sensors, and pain depends on the balance between safety and danger.
EPs primarily advised on active treatment approaches (e.g. exercise and self-management). Quality of care is likely to improve through increasing focus on the systemic benefits of exercise in overcoming psychological barriers (e.g. fear avoidance and pain catastrophising) that may prevent exercise treatment engagement. Broadening PNE to reconceptualise knee osteoarthritis pain as a sign of an overprotective nervous system, rather than structural damage, may facilitate greater patient engagement in exercise therapies, thus improving patient outcomes.

Pain-related fear (PRF) can be a significant factor contributing to the development and maintenance of pain-related disability in individuals with persistent pain. One treatment approach to target PRF and related avoidance behavior is exposure in vivo (EXP). EXP has a long history in the field of anxiety, a field that is constantly evolving. This Perspective outlines recent theoretical advancements and how they apply to EXP for PRF, including suggestions for how to optimize inhibitory learning during EXP; reviews mechanistic work from neuroimaging supporting the targeting of PRF in people with chronic pain; and focuses on clinical applications of EXP for PRF, as EXP is moving into new directions regarding who is receiving EXP (eg, EXP in chronic secondary pain) and how treatment is provided (EXP in primary care with a crucial role for physical therapists). Considerations are provided regarding challenges, remaining questions, and promising future perspectives.
For patients with chronic pain who have elevated pain-related fear (PRF), exposure is the treatment of choice. This Perspective highlights the inhibitory learning approach, summarizes mechanistic work from experimental psychology and neuroimaging regarding PRF in chronic pain, and describes possible clinical applications of EXP in chronic secondary pain as well as in primary care.

To ensure the effective management of patients\' pain, it is important that physiotherapists have a good understanding of the neuroscience behind pain. A major barrier to adequate pain management is that, for patients, there is limited access to clinicians who are knowledgeable about pain. This study examined the level of knowledge regarding pain neurophysiology among physiotherapists currently practicing in Saudi Arabia.
METHODS: The study was a cross-sectional web-based survey that utilized the 12-item Revised Neurophysiology of Pain Questionnaire. Descriptive and inferential statistics were used to describe levels of knowledge regarding pain neurophysiology and to examine differences in knowledge based on the characteristics of the participating physiotherapists (gender, educational level, experience, practice region, and country where their highest educational level was attained).
RESULTS: One hundred and eleven physiotherapists (58.6% male) from various regions and educational backgrounds participated in the study. Out of a maximum Revised Neurophysiology of Pain Questionnaire score of 12, the mean ± standard deviation (SD) was 6.7 ± 2.2; 90% of physiotherapists scored 9 (75%) or less. None of the examined characteristics of the participants were associated with knowledge.
CONCLUSIONS: Physiotherapists in Saudi Arabia showed limited knowledge of the neurophysiology of pain; however, this was not related to the personal characteristics that were examined. The continuation of education in modern pain science is recommended for physiotherapists, especially those dealing with patients suffering from chronic pain.
CONCLUSIONS: The physiotherapists who took part in this study displayed limited knowledge of pain neuroscience; this limited knowledge might suggest the need for a more bio-anatomical approach to pain management. There is a need for tailored medical education to address pain neuroscience knowledge in current physiotherapist practitioners.

Clinical guidelines for the non-surgical management of knee osteoarthritis (OA) recommend exercise and education. This study aimed to evaluate the extent to which accredited exercise physiologists (AEPs) deliver exercise and education for knee OA and how it aligns with clinical practice guidelines.
Cross-sectional survey.
An online survey targeted to AEPs across Australia to understand the exercise and education content of their interventions for knee OA. Likert scale and multiple-choice questions were used to measure responses relating to exercise prescription. Thematic analysis was used to evaluate the nature of education being delivered by AEPs. The revised neurophysiology of pain questionnaire (r-NPQ) was used to quantify pain neuroscience knowledge.
A total of 161 AEPs completed the survey (63 men, 98 women; mean experience 5.8 ± 4.7 years). Exercises commonly prescribed included: strength (99% of respondents), weight bearing (90%) and aerobic (83%), with 98% of AEPs prescribing exercise for the affected and unaffected limb. Only 32% of respondents frequently considered prescribing \'exercise into pain\'. The four main education themes were exercise (86%), self-management (61%), weight loss (56%) and pain management (51%). Specific pain neuroscience education (PNE) was provided by only 21% of respondents.
Exercise prescription mostly aligned with evidence-based recommendations. The education component of AEP interventions for knee OA focused on the benefits of exercise. However, other education guideline recommendations about the disease, appropriate treatments and self-management were underutilised. The PNE knowledge of AEPs was comparable with other secondary care providers, although only a minority of AEPs provide PNE.

The aim of the present study was to explore the pain modulation effects of motor imagery (MI) and action observation (AO) of specific neck therapeutic exercises both locally, in the cervical region, and remotely. A single-blind, placebo clinical trial was designed. A total of 30 patients with chronic neck pain (CNP) were randomly assigned to an AO group, MI group, or placebo observation (PO) group. Pain pressure thresholds (PPTs) of C2/C3, trapezius muscles, and epicondyle were the main outcome variables. Secondary outcomes included heart rate measurement. Statistically significant differences were observed in PPTs of the cervical region in the AO and MI groups between the preintervention and first postintervention assessment. Significant differences were found in the AO group in the epicondyle between the preintervention, first and second post-intervention assessments. Regarding heart rate response, differences were found in the AO and MI groups between the preintervention and average intervention measurements. AO and MI induce immediate pain modulation in the cervical region and AO also induces remote hypoalgesia. OA appears to lead to greater pain modulation as well as a greater heart rate response, however, both should be clinically considered in patients with CNP.

Chronic Low Back Pain (CLBP) is a major and highly prevalent health problem. Given the high number of papers available, clinicians might be overwhelmed by the evidence on CLBP management. Taking into account the scale and costs of CLBP, it is imperative that healthcare professionals have access to up-to-date, evidence-based information to assist them in treatment decision-making. Therefore, this paper provides a state-of-the-art overview of the best evidence non-invasive rehabilitation for CLBP. Taking together up-to-date evidence from systematic reviews, meta-analysis and available treatment guidelines, most physically inactive therapies should not be considered for CLBP management, except for pain neuroscience education and spinal manipulative therapy if combined with exercise therapy, with or without psychological therapy. Regarding active therapy, back schools, sensory discrimination training, proprioceptive exercises, and sling exercises should not be considered due to low-quality and/or conflicting evidence. Exercise interventions on the other hand are recommended, but while all exercise modalities appear effective compared to minimal/passive/conservative/no intervention, there is no evidence that some specific types of exercises are superior to others. Therefore, we recommend choosing exercises in line with the patient\'s preferences and abilities. When exercise interventions are combined with a psychological component, effects are better and maintain longer over time.

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