Discussion
chronic pain, PNE, disability, pain
CHRONIC PAIN, CHRONIC LOW BACK PAIN
Based on the findings, the first study’s hypothesis regarding the effect of PNE followed by PEs on pain and physical limitation was not accepted. Although clinical effectiveness was larger in the group of PNE followed by PEs, no statistically significant differences were observed between the two groups. For the second hypothesis, PNE followed by the PEs group showed only statistically and clinically significant differences compared to the PEs group in psychological outcomes. Finally, no differences were found in the outcome of the function.The effectiveness of prescribing PNE with therapeutic exercise is controversial. Two systematic review studies reported low clinical benefits of PNE in combination with other short- or medium-term therapeutic exercises for reducing pain and disability [To support our results, Lluch et al. (2018) concluded that a preoperative program including PNE (similar to the pain education format of our study) and knee joint mobilization has a superior effect on pain catastrophizing and kinesiophobia over biomedical education and knee joint mobilization in knee OA participants, while, no differences were found for pain and disability [Alongside this, one explanation for the lack of statistical effectiveness of PNE in reducing pain can be related to the number of educational sessions. Whereas in the current study, PNE was provided for three PNE sessions, the previous investigation showed that a higher dosage (six 45-min sessions) produced a larger improvement in pain [Regarding psychological outcomes, one-way pain education could be effective and increase the benefits of PEs associated with its potential to reduce the threat value of pain leading to fear of movements. This is observed that the effectiveness of pain education can achieve by targeting a clear and valid explanation of pain and symptoms in chronic pain participants [Unlike the current results, our previous study showed that individualized PNE combined with motor control training has no additional benefits for pain and disability and psychological factors (e.g., fear-avoidance beliefs and self-efficacy) compared to a group-based intervention in participants with chronic low back pain [One unique procedure we used in the group of PNE followed by PEs was providing the same supervisor (physical therapist A) for both educational pain classes and PEs sessions. We believe this procedure may benefit participants via 1. receiving the same information from the same supervisor, 2. reminding pain education topics while doing PEs, making the educational classes into practice, and 3. better communication of participants with the allocated supervisor during the interventions. In a study by Ryan et al. (2010), the superiority of pain biology education over combined pain biology education and group exercise classes was mentioned because of “mixed information” provided by the supervisors for participants in the combined group [