Efficacy of pain neuroscience communication, motivational interviewing, and cognitive exercise therapy in patients with chronic neck pain

Background:

Recent findings of the Global Burden of Disease Study indicated that neck pain (NP) along with low-back pain ranked as number one on the list of 310 chronic medical conditions in terms of years lived with a disability. This makes sense since Chronic neck pain (CNP) has a very limiting symptomatology, including pain, decreased movement, disability, or impairment of patients’ psychological function.

Although several interventions are available for treating CNP, it is unclear which are most effective, and whether particular subgroups of CNP patients benefit more from specific interventions. In this matter, exercise therapy has been appointed to be highly efficient when combined with other interventions, however, current scientific evidence does not provide clear conclusions as to the most effective exercise type, especially for intermediate-term improvements in CNP patients.

Current clinical practice guidelines recommend a care and support plan that sets out a comprehensive person-centred assessment of the causes and effects of pain, and through
reaching an agreement on possible management strategies.

In this regard, recent studies have revealed an urgent need to invest in high-value person-centred pain care, and for professional and work organizations to similarly promote attention based on these principles. This necessity involves the inclusion of patients' perspectives into models of care and pain training programs, shifting from a disease-centred model to one that promotes health, and focuses on reducing disparities.

However, despite all the scientific work carried out until today, the treatment recommendations and the prevalence of CNP have not significantly changed over the
years.

Objectives:
This thesis is divided into two parts, the following are the objectives of Part I:

• Objective 1: To compare different novel types of exercise therapy aimed at managing chronic neck patients, and to understand the potential association between these exercises and variables related to pain and its biological and psychological domains (Articles I and II).

• Objective 2: To explore the association between psychological variables and other chronic neck-related disorders (specifically, chronic whiplash-associated disorders) (Article III).

The objectives of Part II are presented as follows:

• Objective 3: To assess the routine clinical practice in managing chronic pain in primary health care, and its effectiveness for pain, disability, quality of life and functionality (Article IV).

• Objective 4: Evaluating the effectiveness of a multicomponent complex intervention comprising pain science education, motivational interviewing, and cognition-targeted exercise therapy in patients with chronic neck pain in primary health care physiotherapy (Article V and preliminary results).

• Objective 5: To explore the therapeutic alliance of physiotherapy in primary health care after the multicomponent complex intervention, and to assess the relationship between therapeutic alliance and pain in patients with chronic neck pain (Article VI).

Methodology:

For this thesis, six studies have been conducted. Articles I-III constitute Part I of this dissertation, and Articles IV to VI were carried out for Part II.

Article I is a single-blinded randomised controlled trial in which 54 healthy subjects were recruited and randomised into three groups: a motor imagery group; an action observation group; and an active exercise group. The exercises were performed for 20 minutes in all groups, and the measurement times were before and after the intervention. The main outcomes included conditioned pain modulation (CPM), and pressure pain thresholds.

Article II is a single-blinded randomised clinical trial in which 44 patients with CNP were recruited and randomised into two groups: a virtual reality, and an active neck exercises treatment group. The intervention consisted of two treatment sessions per week for four weeks, the measurement times were baseline, after treatment, and 1-month and 3-month follow-up. The main variables were pain intensity, CPM, temporal summation, and functional and somatosensory outcomes.

Article III is a cross-sectional study that included 120 participants with chronic whiplash-associated disorders. The main outcomes included sociodemographic variables, stress, anxiety, pain catastrophizing, illness perceptions, disability, and post-traumatic stress. A correlation and multiple linear regression analysis were performed.

Article IV is a quasi-experimental longitudinal descriptive observational study in which 99 patients with chronic shoulder pain were recruited. The patients followed seven sessions 60 to 90-minute long, consisting of health education and exercise. The sessions were held two times a week for 3 consecutive weeks, and one last session 2 months after the sixth. The measurement times were at baseline and 2-month follow-up. The main outcome measures were pain intensity and shoulder disability.

Article V sets the protocol for a pragmatic cluster-randomised clinical trial with a 12-month follow-up in which CNP patients and physiotherapists would be recruited from primary health care centres. The intervention proposed consisted of pain science education (PSE), motivational interviewing (MI), and conditioned-targeted exercise therapy (CTET) compared to the standard health education and exercise treatment.

The treatment proposed consists of 5 60-minute weekly sessions, and the physiotherapists allocated to the intervention group received five training sessions on MI, PSE, and CTET. The data collection is settled at baseline, 3-month, 6-month and 12-month follow-up. The main variable is the reduction in pain intensity.

Article VI Secondary analysis for a parallel-group- two-arm pragmatic-cluster randomised clinical trial with a 1:1 allocation ratio in which 129 patients with CNP, and 21 clinicians from 14 primary health care centres were included. The intervention was carried out as established in Article V. The measurement times were after the intervention and 3-month follow-up. The main outcome was therapeutic alliance.

Results:
Concerning Part I, in Article I changes in CPM, muscle endurance, and attention were observed within the active exercise and action observation groups. In addition, all groups showed positive changes in pressure pain thresholds, with improvements in neck range of motion observed only in the active exercise group, and the ability to create motor images observed only in the action observation group.

In Article II, it was found that virtual reality is not superior to active exercise in improving pain intensity, CPM, range of motion of the neck, disability, pain catastrophizing, fear-avoidance beliefs, anxiety, or pressure pain thresholds in patients with CNP. However, kinesiophobia showed statistically significant differences in favour
only of the virtual reality group at 3 months after the intervention.

Article III showed that there is a positive correlation between stress and anxiety in patients with chronic whiplash-associated disorders. The study also revealed pain catastrophizing and other psychological factors related to pain are connected to theduration of the symptoms after the injury. Additionally, these patients tend to have higher scores in different subscales of illness perceptions (identity, and personal and treatment
control). Moreover, anxiety, disability, and illness perceptions account for most of the variance in stress levels, and stress, catastrophizing, and illness perceptions, the variance in anxiety levels.

In Article IV, it was demonstrated that a treatment involving health education and exercise effectively reduced pain and disability in patients with chronic shoulder pain. Furthermore, these patients did not return to the primary health care centre for the same complaint, and had also ceased using anti-inflammatory drugs.

In Part II, the preliminary results of Article V showed no statistically significant between-group differencesfor the primary outcome (pain), however, both groups showed clinically relevant changes in pain intensity at 3, 6, and 12 months after the intervention. With respect to the secondary outcomes, statistically significant changes were found only for the therapeutic alliance, in favour of the intervention group.

Finally, Article VIrevealed that the intervention group had statistically significant higher therapeutic alliance than the control group. There was also a positive moderate correlation between higher therapeutic alliance and lower pain intensity three months after the intervention for patients with CNP receiving physiotherapy in primary health care.

Conclusions:

Conclusions of Part I:

Article I: AE and AO can lead to improvements in CPM, cervical muscle endurance, and attention in asymptomatic participants but only AE is effective in improving CROM, and only AO enhances the patient’s ability to generate motor images.

Article II: VR is not more effective than AE in improving pain intensity, CPM, CROM, neck disability, pain catastrophizing, PPT or anxiety in patients with CNP. However, it is more effective in improving kinesiophobia.

Article III: Strategies to manage stress and anxiety could help reduce pain catastrophizing and improve functionality in patients with cWAD.

Conclusions of Part II:

Article IV: The implementation of a health education program that includes active exercise in the treatment of chronic shoulder pain, can be useful in the improvement of this condition from the primary health care perspective.

Article V and preliminary results: An intervention comprising PSE, MI, and CTET is effective in achieving clinically relevant differences in psychological and biological outcomes in the long term, however, these changes are not significantly stronger than the control group in primary health care in patients with CNP.

Article VI: The combination of PSE, MI, and CTET is more effective in developing a strong TA . Additionally, stronger TA is moderately correlated with a higher improvement in pain intensity in CNP patients.