Exercise and pain neuroscience education (PNE) have both been used as standalone treatments for chronic musculoskeletal pain. The evidence supporting PNE as an adjunct to exercise therapy is growing but remains unclear. The aim of this systematic review and metaanalysis was to evaluate the effect of combining PNE and exercise for patients with chronic musculoskeletal pain, when compared with exercise alone. A systematic search of electronic databases was conducted from inception to November 6, 2020. A quality effects model was used to meta-analyze outcomes where possible. Five high-quality randomized controlled studies (n 5 460) were included in this review. The PEDro scale was used to assess the quality of individual studies, and Grading of Recommendations, Assessment, Development, and Evaluation analysis was conducted to determine the quality of evidence for each outcome. Meta-analyses were performed for pain intensity, disability, kinesiophobia, and pain catastrophizing using data reported between 0 and 12 weeks postintervention. Long-term outcomes (.12 weeks) were only available for 2 studies and therefore were not suitable for meta-analysis. Meta-analysis revealed a significant difference in pain (weighted mean differences, 22.09/10; 95% confidence interval [CI], 23.38 to 20.80; low certainty), disability (standardized mean difference, 20.68; 95% CI, 21.17 to 20.20; low certainty), kinesiophobia (standardized mean difference, 21.20; CI, 21.84 to 20.57; moderate certainty), and pain catastrophizing (weighted mean differences, 27.72; 95% CI, 212.26 to 23.18; very low certainty) that favoured the combination of PNE and exercise. These findings suggest that combining PNE and exercise in the management of chronic musculoskeletal pain results in greater short-term improvements in pain, disability, kinesiophobia, and pain catastrophizing relative to exercise alone.

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Objectives: 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. Design: Cross-sectional survey. Method: 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. Results: 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. Conclusions: 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.

This study shows that aerobic training increases pressure pain threshold in pain-free adults. This effect was observed only for MICT over-exercised muscles, implying intensity- and site-specific effects of exercise training on pain threshold.

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Objectives To explore how Australian exercise physiologists (EPs) utilise pain neuroscience education (PNE) in their management of patients with knee osteoarthritis. Methods 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. Results 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. Conclusion 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.

BackgroundIntensity is an important determinant of physiological adaptations and health benefits of exercise, but the role of exercise intensity on improving outcomes in people with chronic low back pain (CLBP) is unclear. This systematic review aimed to determine the effect of higher versus lower intensity exercise intensity on pain, disability, quality of life and adverse events in people with CLBP.MethodsSix databases and four clinical trial registries were searched from inception to 21 December 2022, for randomised controlled trials that compared two or more exercise intensities in adults with CLBP. Data were analysed using random‐effects meta‐analysis for disability and synthesised narratively for pain, quality of life and adverse events due to limited studies. Risk of bias was assessed using the Cochrane tool and certainty of evidence was evaluated using Grading of Recommendations, Assessment, Development and Evaluations framework.ResultsFour trials (n = 214 participants, 84% male) reported across five studies were included. Higher intensity exercise reduced disability more than lower intensity exercise at end‐treatment (SMD [95% CI] = −0.39 [−0.56 to −0.22]; very low certainty) but not at 6‐month follow‐up (SMD [95% CI] = −0.20 [−0.53 to 0.13]; very low certainty). Higher intensity exercise did not reliably improve pain and quality of life more than lower intensity exercise. Adverse events did not differ between exercise intensities. All studies were at high risk of bias.ConclusionBased on very low certainty evidence from a limited number of studies, exercise intensity does not appear to meaningfully influence clinical outcomes in people with CLBP.