Neuromuscular exercise and pain neuroscience education compared with pain neuroscience education alone in patients with chronic pain after primary total knee arthroplasty: study protocol for the NEPNEP randomized controlled trial

Abstract

Background: Total knee arthroplasty (TKA) is considered an effective treatment for pain relief and improved physical performances in end-stage knee osteoarthritis. However, several studies have reported less favorable outcomes after TKA with chronic pain rates of approximately 20%. Exercise might be an effective treatment strategy for chronic pain following TKA, but no randomized controlled trials have evaluated its effect. Therefore, the purpose of this randomized controlled trial is to investigate whether a 12-week neuromuscular exercise (NEuroMuscular EXercise training program for patients with knee or hip osteoarthritis assigned for total joint replacement; NEMEX-TJR) program combined with pain neuroscience education (PNE) provides greater pain relief and improvement in physical performances than PNE alone at 12 months follow-up in a population of patients with chronic pain after primary TKA. Methods: For this randomized controlled superiority trial, 120 patients with moderate-to-severe chronic pain after TKA are recruited from Aalborg University Hospital, Denmark. Patients are randomly assigned in a 1:1 ratio to one of two interventions: (a) NEMEX-TJR twice weekly for 12 weeks combined with two sessions of PNE or (b) two sessions of PNE given over 6 weeks. Assessment is performed at baseline before intervention and at 3, 6, and 12 months after initiation of the intervention. Outcome assessors are blinded toward group allocation. The primary outcome is the change in the Knee Injury and Osteoarthritis Outcome Score 4 (KOOS 4), defined as the mean score for the KOOS subscales pain, symptoms, activities of daily living, and quality of life. Secondary outcomes include all KOOS subscale scores and scores for PainDETECT, the Fear-Avoidance Beliefs Questionnaire, Global Perceived Effect, the Pain Catastrophizing Scale, pain intensities, temporal summation, conditioned pain modulation, and pressure pain thresholds. Physical performances are measured with walking, stair climbing, and chair standing tests as well as tests of muscle strength and power.

Effects of Pain Neuroscience Education Combined with Lumbar Stabilization Exercise on Strength and Pain in Patients with Chronic Low Back Pain: Randomized Controlled Trial

“…It has been shown that neuroscience education is effective in improving muscle strength. In this study, PNE increased the patients' interest in functional activity and exercise and motivated them to perform more frequent and intense activities, thereby improving physical ability and reducing pain [47]. In addition, PNE has been reported to have a positive effect of changing incorrect pain beliefs and incorrect movements of the lower back [23], thus allowing patients to more actively participate in the LSE program without fear of exercise.…”

Positive effects of neuromuscular exercises on pain and active range of motion in idiopathic frozen shoulder: a randomized controlled trial

“…Ginn et al [25] demonstrated that exercises to restore neuromuscular control were as effective as corticosteroid injections in treating shoulder pain in the short term. In addition to the shoulder, NME has a significant therapeutic effect on many other musculoskeletal pain conditions, such as low back pain [39,40], neck pain [41], chronic musculoskeletal pain in the elderly [42], chronic pain after primary total knee arthroplasty [43], and knee and hip osteoarthritis [44,45]. NME includes active exercises of strength, coordination, balance, and proprioception.…”

Pain Neuroscience Education Combined with Therapeutic Exercises Provides Added Benefit in the Treatment of Chronic Neck Pain

“…The compound and development of the pain neuroscience education intervention were based on previous studies [17,[38][39][40]. Pain neuroscience education discussed peripheral sensitization, central sensitization, and biopsychosocial factors associated with pain [19,41].…”

“…The sessions covered topics concerning the multifactorial nature of chronic pain, sensitization, and plasticity of the brain, aiming at giving patients a better understanding of their chronic pain and thereby engaging the patients in the treatment. [39]. Patients were also taught items such as the physiology of the synapse, the neuron (receptor, axon, and terminal), descending nociceptive inhibition and facilitation (the influence of cognitive factors, notion, motor activities, etc.…”