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Effectiveness of a Pain Neuroscience Education and Therapeutic Exercise Program Delivered by Primary Care Physiotherapists to Patients With Chronic Nociplastic Spinal Pain

Not Applicable
Not yet recruiting
Conditions
Chronic Pain (Back / Neck)
Registration Number
NCT07133607
Lead Sponsor
Distrito de Atención Primaria Sevilla
Brief Summary

The main objective of the project is to evaluate the effectiveness, in terms of quality of life, of a therapy based on an Active Coping Protocol for Non-Cancer Chronic Pain in the Primary Care setting. This approach involves no medications or invasive procedures and is based on pain neuroscience education and physical exercise, either alone or combined with treatment targeting body schema and somatosensory disturbances. The comparison will be made against a treatment involving thermotherapy and traditional physical exercise.

One of the most well-documented national primary care experiences combining pain neuroeducation and physical exercise, with a detailed methodology, was carried out by the Health System of Castilla y León (Sacyl) in Valladolid. It yielded significant results using a protocol consisting of 6 sessions of pain neuroscience education and 18 sessions of group exercise.

Based on this reference study, two hypotheses are proposed: the first is that reducing the number of sessions in the Active Coping Protocol for Chronic Pain would maintain treatment effectiveness. The second hypothesis suggests the potential for improved outcomes by combining the Active Coping Protocol with body schema and somatosensory disturbance treatment.

To test these hypotheses, a randomized experimental study with three parallel groups will be conducted on patients aged 18 to 70, referred to Physiotherapy from health centers in the Sevilla Health District. These patients experience daily spinal chronic pain for more than 3 months or on at least half of the days over more than 6 months, with central sensitization as the underlying cause.

Effectiveness will be measured in terms of quality of life (SF-36), pain intensity (Visual Analog Scale), satisfaction level, kinesiophobia, catastrophizing, pressure pain threshold, disability index (NDI/Oswestry), medication reduction, and number of monthly medical appointments.

Secondary objectives include evaluating, in both experimental groups compared to the control, the outcome variables: pain intensity, treatment adherence, kinesiophobia, catastrophizing, pressure pain threshold, descending modulation system, lumbar disability index, severity level, anxiety, sleep quality, analgesic consumption, healthcare visits, and satisfaction with care received.

A sample size of 135 patients has been calculated and will be randomized into the three study groups. The control group will receive thermotherapy-electrotherapy and conventional therapeutic exercise. Experimental group 1 will follow the Active Coping Program for Chronic Pain (4 education sessions and 12 physical exercise sessions). Experimental group 2 will receive somatosensory and body schema treatment along with the Active Coping Program.

The study is evaluator-blinded. Statistical analysis will be performed using SPSS version 28 and R Core Team (2023). Statistical significance will be set at p-values \<0.05. Authorization will be requested from the relevant Research Ethics Committee.

The results of this study may lead to updates of existing protocols, development of guidelines and manuals for managing chronic musculoskeletal pain, ongoing training for primary care professionals, and publication in high-impact scientific journals to disseminate knowledge.

Detailed Description

Not available

Recruitment & Eligibility

Status
NOT_YET_RECRUITING
Sex
All
Target Recruitment
135
Inclusion Criteria
  • Users of the Public Health System of Andalusia, registered in the User Database (BDU) of the Sevilla Health District.
  • Ages between 18 and 70.
  • Chronic lumbar pain lasting more than 3 months, likely due to central sensitization (likely nociplastic pain).
  • The diagnosis of Central Sensitization will be made according to the most recent algorithm published by Nijs et al. in Lancet.
Exclusion Criteria
  • Oncological pain (pain related to cancer)
  • Spinal fracture or spinal surgery in the previous year.
  • Neurological cognitive impairment that prevents understanding of pain neuroeducation (if in doubt, the Minimental Test will be performed, requiring a minimum score of 25)
  • Physical conditioning deficit that prevents the execution of the Physical --Education program (minimum requirement: normal execution time of <10 seconds for the timed "Up and Go" test).
  • Pregnancy
  • Cauda equina syndrome
  • Chronic fatigue syndrome
  • Fibromyalgia
  • Complex Regional Pain Syndrome
  • Clinical conditions that may aggravate chronic spinal pain.
  • Associated pathologies that prevent the performance of a physical exercise program (myopathies and neurological disorders).
  • Currently undergoing alternative therapies.
  • The presence of pain in other anatomical regions, apart from spinal pain, is not a reason for exclusion.

Study & Design

Study Type
INTERVENTIONAL
Study Design
PARALLEL
Primary Outcome Measures
NameTimeMethod
Change from Baseline in the value of quality of life measured Trough sf 36 questionnaire at 6 Monthsfrom the start of treatment, at 11 weeks and at 26 weeks

0 equals very poor quality of life and 100 very good quality of life

Secondary Outcome Measures
NameTimeMethod
Change from Baseline in the value of regular physical activity measured Trough international physical activity questionnaire (IPAQ)at 6 Monthsfrom the start of treatment, at 11 weeks and at 26 weeks

low/moderate/high

Change from Baseline in the value of kinesophobia measured Trough kinesophobia questionnaireTampa-TSK-11SV at 6 Monthsfrom the start of treatment, at 11 weeks and at 26 weeks

The lowest possible score, 11, denotes negligible or nonexistent kinesiophobia. The highest possible score, 44, denotes a severe fear of experiencing pain when moving.

Change from Baseline in the value of satisfaction with health services of the case at 6 Months trough The Spanish version of the Client Satisfaction Questionnaire (CSQ-8)from the start of treatment, at 11 weeks and at 26 weeks
Change from Baseline in the value of Regular physical activity of the case at 6 Months trough International Physical Activity Questionnaire (IPAQ).from the start of treatment, at 11 weeks and at 26 weeks
Change from Baseline in the value of fatigue intensitivity measured trough AVS scale at 6 Monthsfrom the start of treatment, at 11 weeks and at 26 weeks

0 equals absence of fatigue and 10 a lot of fatigue

Change from Baseline in the value of short stress test at 6 Months trough number of squats in 30 seconds, 60 seconds, and modified Borg scale of perceived exertionfrom the start of treatment, at 11 weeks and at 26 weeks

0 equals absence of perceived exertion and 10 a lot of perceived exertion

Change from Baseline in the value of Flamingo Balance Test at 6 Months trough number of times you need to land in 30"from the start of treatment, at 11 weeks and at 26 weeks
Change from Baseline in the value of pain intensitivity measured trough AVS scale at 6 Monthsfrom the start of treatment, at 11 weeks and at 26 weeks

0 equals absence of pain and 10 a lot of pain

Change from Baseline in the value of Pain Catastrophizing measured Trough Pain Catastrophizing Scale (PCS) at 6 Monthsfrom the start of treatment, at 11 weeks and at 26 weeks

Together with three subscale scores assessing rumination, magnification, and helplessness, the overall score has a range of 0-52.

Higher scores indicate a greater degree of pain catastrophizing. A total score \>30 represents a clinically significant level of pain catastrophizing.

Change from Baseline in the value of pain threshold to pressure at 6 Months trough the protocol described in the study by Neziri et al, measuring four points using the procedure described by Fisherfrom the start of treatment, at 11 weeks and at 26 weeks

A pain threshold below 4 kg/cm2 identifies increased sensitivity to pressure.

Change from Baseline in the value of lumbar disability index measured Trough Rolland Morris Scale at 6 Monthsfrom the start of treatment, at 11 weeks and at 26 weeks

The final score, out of 24 represents the degree of disability due to low back pain. A maximum score of 24 indicates the greatest degree of disability from back pain.

Change from Baseline in the value of Conditional pain modulation system at 6 Months trough Protocol validated by Larsen et al.from the start of treatment, at 11 weeks and at 26 weeks

The UDP is assessed in the anterior tibial muscle (three times to calculate the mean), then, using a conditioning clamp, a tonic pain stimulus is applied by pinching the earlobe for 60 seconds (10). When the VAS of earlobe pain exceeds 60 mm, the pressure pain threshold in the anterior tibial muscle is assessed again three times. The CPM effect is calculated as the percentage change \[(conditioning/baseline × 100) - 100\] and the difference \[conditioning-baseline\] in the pressure pain threshold as recommended by Yamitsky D. et al.

Change from Baseline in the value of Level of severity of the case at 6 Months trough the Central Sensitization Inventoryfrom the start of treatment, at 11 weeks and at 26 weeks

0 equals absence of severity associated with central sensitization and 100 a lot of severity associated

Change from Baseline in the value of sleep quality and patterns in adults of the case at 6 Months trough The Pittsburgh Sleep Quality Questionnaire (PSQI)from the start of treatment, at 11 weeks and at 26 weeks

It provides a global measure of sleep quality, with a range of 0 to 21, where scores greater than 5 suggest significant alterations in sleep quality

Change from Baseline in the value of Medication intake of the case at 6 Months trough a surveyfrom the start of treatment, at 11 weeks and at 26 weeks

The results will be expressed in weekly doses according to the type of drug taken.

During the follow-up period, visits to the family doctor, emergency services, and specialists will be recorded using the Digital Health Record.from the start of treatment, at 11 weeks and at 26 weeks

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