R E S E A R C H R E P O R T

Pain Neuroscience Education and Exercise for Neck Pain: A Focus Group Study
on Adolescents’ Views
Maritza Neto, MSc; Rosa Andias, MSc; Anabela G. Silva, PhD
School of Health Sciences (Mss Neto and Andias and Dr Silva) and CINTESIS-UA (Dr Silva), University of Aveiro, Aveiro, Portugal.

Purpose: To explore the views of adolescents with chronic idiopathic neck pain toward an intervention consisting of pain
neuroscience education and exercise administered in the school setting.
Methods: Four focus group interviews were conducted with 21 adolescents with chronic idiopathic neck pain who
participated in a 4-week intervention consisting of pain neuroscience education and exercise. The interviews were
transcribed verbatim and analyzed using content analysis.
Downloaded from http://journals.lww.com/pedpt by BhDMf5ePHKbH4TTImqenVEDrSV46uWgJANA4DVoVYfKZUKWJr72KlJw2rhif/3HABpYO6gVvnXo= on 07/13/2018

Results: Two main themes emerged: the perceived relevance of acquired knowledge and the perceived adequacy of the
intervention.
Conclusion: An intervention consisting of pain neuroscience education and exercise administered in the school setting is
well accepted and considered relevant and appropriate by adolescents with chronic idiopathic neck pain. (Pediatr Phys Ther
2018;30:196–201)
Key words: adolescents, exercise, focus group, neck pain, pain neuroscience education

INTRODUCTION and participating in physical education.8 It is associated with a

Musculoskeletal pain affects up to 40% of children and
adolescents,1,2 of which approximately 60% report difficul-
ties performing leisure activities, 48% report difficulties sit-
ting during a lesson, and 34% report difficulties falling asleep.2
Neck pain (NP) affects 17.2% of adolescents2 and its preva-
lence has increased.3 Several reasons are suggested for the
high and increasing prevalence of NP, such as increased seden-
tary behavior, increased use of new information technologies,4
increased sleeping difficulties,5 and decreased psychosocial
well-being,5 all of which have been associated with NP.6-8 Sim-
ilar to general musculoskeletal pain, NP in adolescents has
also been associated with difficulties in leisure activities, sitting,
0898-5669/110/3003-0196
Pediatric Physical Therapy
Copyright © 2018 Academy of Pediatric Physical Therapy of the American
Physical Therapy Association
Correspondence: Anabela G. Silva, PhD, School of Health Sciences, Univer-
sity of Aveiro, Campus Universitário de Santiago, 3810-193 Aveiro, Por-
tugal (asilva@ua.pt).
All procedures performed were in accordance with the ethical standards
of the institutional and national research committee and with the 1964
Helsinki Declaration and its later amendments or comparable ethical stan-
dards. Informed consent was obtained from all individual participants and
from their legal guardian when participants were younger than 18 years.
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0000000000000511
higher probability of having NP in adulthood.9
In adults, pain neuroscience education is promising,10 con-
sisting of educational sessions describing the neurobiology and
neurophysiology of pain and pain processing. This interven-
tion has a positive effect on pain, disability, catastrophizing,
and physical performance in adults, especially if combined
with exercise.10,11 One of the mechanisms through which pain
neuroscience education is believed to facilitate exercise is by
changing maladaptive pain beliefs and cognition such as catas-
trophizing and fear of movement, which are associated with
exercise avoidance.12 Its effectiveness is likely to depend on the
ability of physical therapists to communicate complex concepts
in laypersons’ terms using examples and metaphors that relate to
the individuals’ daily lives. Conceivably, examples, metaphors,
and resources used for adults need to be adapted when used
with adolescents. Research using pain neuroscience education
in adolescents with NP is scarce. Pain neuroscience education
for adults is usually delivered in clinical settings, but school has
been advocated as a more appropriate setting to deliver health
interventions for children and adolescents,13 as this is where
children and adolescents spend most of their time. School-
based interventions may facilitate access to care at early stages
of the disorder,13,14 while raising awareness on the importance
of managing chronic pain.
It is important to determine how well an intervention will be
received by the target population, whether it is perceived as rele-
vant and the extent to which the intervention meets the needs of
the target population and setting.15,16 Although both quantita-
tive and qualitative research can be used to address these issues,

196 Neto et al Pediatric Physical Therapy

Copyright © 2018 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
the latter gives a more in-depth view on the participants’ per-
ceptions of the intervention and what should be modified.17-19
Qualitative research may inform on the potential mechanisms
of action of the intervention and identify potential barriers to
behavior change that the intervention aims to achieve.20 The
aim of this study was to explore the views of adolescents with
NP toward an intervention consisting of pain neuroscience edu-
cation and exercise given in the school setting.
METHODS
This qualitative study followed a quantitative, randomized,
and controlled trial with adolescents aged 16 to 18 years with
chronic idiopathic NP. Idiopathic NP is defined as pain felt for
3 months or longer and for which no cause had been established.
This trial is described in Andias et al.21 At the completion of the
intervention, the experimental group (n = 21) participated in
focus group interviews. The study was approved by the Ethics
Committee of the Social and Health Sciences Department, Fac-
ulty of Medicine, Porto University. Both participants and their
legal guardians (if participants were younger than 18 years) pro-
vided written informed consent before participating.
Students from the 10th to 12th grades of one high school
(n = 149) were screened for inclusion in the trial, of which
45 met the inclusion criteria and 43 were accepted to par-
ticipate in the study. Of these, 22 were in the control group,
which received no intervention, and 21 were in the experimental
group and received pain neuroscience education and neck and
shoulder endurance exercises. This intervention was adminis-
tered in groups of 4 to 6 participants once a week over 4 consec-
utive weeks. Each session took between 45 minutes to 1 hour.
The authors, all physical therapists, had years of clinical experi-
ence and pain neuroscience teaching experience and conducted
all sessions. These took place in a room that was part of the
physical education teaching facilities at the school.
Pain neuroscience education covered the neurophysiology
of pain, transition from acute to chronic pain, and the ability to
modulate the pain experience22,23 (Table 1). It was delivered in
a manner consistent with international recommendations.22,23
The theoretic information was complemented with pictures and
diagrams.22,23 A booklet summarizing the contents of each
session and using a mixture of text, figures, and activities to
perform between sessions was given to participants with lan-
guage appropriate for adolescents. Time devoted to pain neu-
roscience education decreased from session 1 (45 minutes) to
session 4 (15 minutes).
Exercises were aimed at increasing the endurance and
strength of the deep neck flexor and extensor muscles24 and of
the scapulae stabilizer muscles,25 as these types of exercises have
been found beneficial to improve function and reduce pain.26,27
While these recommendations are for adults, adolescents have
decreased neck flexor and neck extensor endurance when com-
pared with sex and age-matched asymptomatic adolescents.28
Participants received the same exercises delivered over 3 ses-
sions: 1 session per week over 4 weeks with the first session on
pain neuroscience education only. The number of exercises tar-
geting the same group of muscles increased from 1 in the second
session to 2 to 3 in the fourth session and from a total duration
of 15 minutes in session 2 to 30 minutes in session 4. Each exer-
cise was performed in 3 to 4 series of 10 repetitions.
Baseline and postintervention assessments included pain
intensity, muscle strength, state and trait anxiety, catastro-
phizing, and knowledge of pain neurophysiology. At completion
of the intervention, participants completed the Patient’s Global
Impression of Change Scale.29
Focus Group Interviews
The study included 4 focus group interviews. Data col-
lection took place at the participants’ school. The interviews
were semistructured using open-ended questions (Table 2), and
lasted 30 to 45 minutes (Table 2). All authors were present in
all interviews and took notes. Participants were told that their
opinion was of great relevance and that both the positive and
negative aspects were equally important. The interview was con-
ducted in an informal tone to increase participants’ comfort in
discussing their perspectives and thoughts. All participants were
prompted to participate. The facilitator decided when the dis-
cussion of a question had reached saturation and would ask par-
ticipants whether they had anything more to add to the topic
before moving on. All interviews were audio-recorded, tran-
scribed verbatim by the interviewer, and analyzed using content
analysis. The study was reported using the consolidated criteria
for reporting qualitative research items (COREQ; items1-4, 9-
21, 24-26, and 29-32).30

TABLE 1
Pain Neuroscience Concepts, Resources, and Home Activities Given to Students During the Pain Neuroscience Sessions

Examples of Resources Used

Pain Neuroscience Concepts to Illustrate Concepts Examples of Home Activities

Normal pain processing, including
transduction, conduction, transmission,
modulation, and perception
Chronic pain definition and changes that
occur in the normal pain processing with
the transition from acute to chronic pain
Pain modulation and the influence of
maladaptive processes and cognitions on
pain perception
Importance of exercise and how it helps
recovery
Images of the pain processing circuit
Videos from YouTube describing pain processing
Images of the pain neuromatrix
Image of the homunculus
Lion metaphor using pictures of lions of different
sizes (baby lion vs an adult lion) and the
corresponding sound
Image of the fear-avoidance model
Explain normal pain processing in your own
words
Explain chronic pain in your own words
Word search puzzles
Make connections between important words
and respective definitions
Pictures of exercises to do at home and an
exercise diary

Pediatric Physical Therapy Pain Neurophysiology Education and Exercise for Neck Pain 197

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 TABLE 2 TABLE 4
Focus Group Plan Scores Pre- and Postintervention

Focus Group Parts Tasks Performed Mean

Part 1. Opening Introduction of participants to each other and
to the topic of research.
Participants were reminded that there were no
right or wrong answers and that all
participants’ views should be treated with
respect.
Part 2. Discussion The following sequence of questions was used
to prompt discussion:
1. What is your opinion on these sessions?
2. Were the sessions interesting?
3. Were the sessions well structured? What
would you change?
4. Did the sessions help you? In what ways?
5. Could you synthesize the sessions in
1 word?
Part 3. Closing The facilitator reviewed and summarized the
discussion points with participants and
asked them whether there was anything else
they would like to add. At the very end, the
facilitator thanked all participants for their
participation.
Data Analysis
Thematic analysis was conducted using an inductive
approach. Transcripts were read several times for an in-depth
familiarization and codes generated (ie, issues relevant for the
research question). Related codes were then merged into recur-
rent themes.31 The 3 members of the research team indepen-
dently analyzed the transcripts and generated themes, which
were compared and discussed until agreement was reached.
A final report of the analysis of interviews was prepared in
Portuguese and translated to English for this article. Trans-
lation was done by one of the authors and checked by the
other authors. Attention was given to maintaining conceptual
equivalence, rather than lexical similarity during the translation
process.16
RESULTS
Sample Characteristics
Demographic and clinical characteristics are shown in
Tables 3 and 4 and perceived impressions of change postinter-
vention are in Table 5.
Preintervention Postintervention Change
Mean (SD) Mean (SD) (SD)
Pain intensity (VAS) 2.6 (1.5) 1.6 (1.7) − 1.0 (1.4)
Pain Catastrophizing 20.2 (10.3) 14.1 (11.2) − 6.2 (6.5)
Scale
Neurophysiology of 5.7 (2.5) 15.6 (2.6) +9.9
Pain Questionnaire
Abbreviations: SD, standard deviation; VAS, 10-cm visual analog scale.
Focus Group Interviews
Analysis of the transcripts identified 2 themes: perceived rel-
evance of acquired knowledge and perceived adequacy of the
intervention.
Perceived Relevance of Acquired Knowledge. This
theme was divided into 3 subthemes: perceived relevance of
acquired knowledge, perceived relevance of acquired knowl-
edge as a complement to exercise, perceived relevance of
acquired knowledge as a means to facilitate pain reconceptu-
alization and management.
Perceived Relevance of Acquired Knowledge. Participants
valued the acquisition of knowledge on pain neurophysiology
and its contribution to a better understanding of pain. They
expressed this by general positive statements such as:
… I think it was interesting and we now have more knowl-
edge on how things work inside our body, and on the processes
involved in pain and why we have pain. (Female, group 2)
… we had pain, but we never thought how it was caused and
why we had it; we learned that our pain is chronic and what we
can do to decrease it … (Female, group 4)
This [the pain neuroscience education] was very important
and the knowledge I acquired here will certainly be beneficial
throughout my life …. (Male, group 1)
Perceived Relevance of Acquired Knowledge as a Com-
plement to Exercise. Participants highlight the complementarity
between pain neuroscience education and the exercises and the
relevance of pain neuroscience education on changing how they
perceived exercise and its role on improving their NP.
We have to try and remember everything we learned and say to
ourselves: ok, no, this is chronic pain, and I can control it, and
do the exercises … (Female, group 1)

TABLE 3
Demographic Characteristics

Participants Group 1 Group 2 Group 3 Group 4 Total

Grade 11 11 12 12 4
Number of participants 4 6 6 5 21
Sex
Boys 2 3 1 3 9
Girls 2 3 5 2 12
Age, mean (SD), y 16.25 (0.50) 17.67 (2.25) 17.50 (0.84) 18.00 (0.71) 17.43 (1.40)

Abbreviation: SD, standard deviation.

198 Neto et al Pediatric Physical Therapy

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 TABLE 5
Perceived Impression of Change Postintervention
Global Impression of Change Scale Items
1. No change (or condition has got worse)
2. Almost the same, hardly any change at all
3. A little better, but no noticeable change
4. A little better, but no noticeable change
5. Moderately better, with a slight but
noticeable change
6. Better and a definite improvement that
has made a real and worthwhile difference
7. A great deal, better with a considerable
improvement that has made all the
difference
The enhancement of self-efficacy was also evident when par-
ticipants acknowledge being more in control of their NP.
Participants, n (%)
… now we have the knowledge to face the problem [NP] …
0 (Male, group 1)
0
0 Well, I believe that now we are in control of the situation [NP]
3 (14.3) (Female, group 4)
8 (38.1)
While some participants managed pain, others recognize
8 (38.1) that, despite feeling more able to manage pain and to behave in
a more adjusted manner, it is a process that is not yet complete.
2 (9.5)
Participants use the lion metaphor from the pain neuroscience
education sessions21 to illustrate how they feel and where they
are in the process of managing their pain:

Now the lion is not big, it is cute! (Female, group 2)

… now we understand that the exercises help! (Female,
group 3)
Perceived Relevance of Acquired Knowledge as a Means
to Facilitate Pain Reconceptualization and Management. The
knowledge acquired during the program was seen as a facilitator
of changes in terms of feelings, attitudes, and behaviors toward
pain. The understanding of the neurophysiological mechanisms
underlying chronic pain changed how adolescents reacted when
in pain, favoring more adjusted behaviors.
Now we know that when the pain comes we do not have to stop
[exercise/movement] … (Female, group 4)
I used to avoid doing what pain did not let me, and now I do it
without thinking about the pain; otherwise I will get used not to
do [neck] movements because of it (Male, group 2)
Before, I avoided doing certain movements; I had a tendency
to only rotate my neck to the left, I never turned my neck to
the right and, then, it [the neuroscience of pain education]
helped me to not be afraid of moving it [the neck] … I have to
change my thoughts, I have to change this way of mine to see
things because if I do not change it my muscles do not work and
then it is harder (Female, group 1)
The change of attitude, feelings, and behaviors toward pain
were related to a decrease in anxiety, fear, and catastrophizing
and to an increased sense of self-efficacy.
The sessions helped us not to worry that much about pain,
because that can bring anxiety and fear. (Female, group 4)
If it [the NP] comes back, I would know how to deal with it in a
way that is better than before; before I worried a lot, got much
more anxious … (Female, group 3)
I think that from now on, we are more aware of what we can do
to improve our pain (Female, group 3)
… perhaps we used to spend too long worrying about the pain
we had … now, we can deal with it, … try not to value it, try to
distract ourselves and if we are able to do this then the pain will
disappear; because before the sessions we were always worried:
maybe my neck is damaged, maybe it is something serious, and
now we know that it is not worth giving it [the NP] that much
importance and, thus, our well-being also improves. (Female,
group 1)
It is a medium size lion, because I feel that I need to work
harder so that the medium lion becomes a baby lion. (Female,
group 1)
Despite not being completely in control of their pain, these
participants know what they need to do in order to be able
to adequately manage their NP. In particular, they highlight
the importance of the change of attitude and behavior toward
pain and believe that exercises were important in the process of
recovery and pain modulation.
... we will try to forget the pain, so that the big lion does not
come back. (Female, group 4)
... as that lion thing [the lion metaphor used during neuro-
science sessions], we need to try not to give much importance
to it [NP], try to distract ourselves from it [NP] ... (Female,
group 3)
We need to do more exercises so that we can increase the
strength of our muscles, because now we know what we need
to do, so that we get better (Female, group 4)
… I think I have to improve physically and do the exercises
we learned more often …, they should be done every day or
frequently …, I have to be better at this so that I reach my
well-being! (Female, group 1)
Participants agreed with each other regarding the relevance
of pain neuroscience education and its effect on their attitudes,
feelings, and behavior toward pain, as well as on its effect on
their ability to manage their pain.
Perceived Adequacy of the Intervention. The interven-
tion was well accepted by all participants, was considered useful,
and the materials and strategies used to implement it were
deemed appropriate. Different words were used by participants
to characterize it: “useful,” “relevant,” “interesting,” “beneficial,”
“hard work,” “good,” “positive,” “excellent,” and “productive.”
All participants considered the combination of pain neuro-
science education and exercises as being appropriate, relevant,
and complementary (n = 21).
… it was important to combine theory, for us to learn more …
as well as practice [exercises], so that we know small exercises
that we can do at home … (Female, group 3)

Pediatric Physical Therapy Pain Neurophysiology Education and Exercise for Neck Pain 199

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 We focused on a more theoretical component [pain neuro-
science education], maybe because this was the new thing,
but as it is obvious, the practical component [exercise] is very
important. (Male, group 1)
Participants pointed out the intelligibility of the language
used to explain pain neuroscience and the benefits of the group
sessions opposed to one-to-one sessions, as this allowed them
to know others in the same situation (shared experience):
I also think that the simplicity of the language used was impor-
tant …, words were not very difficult, so that we keep it in our
memory … (Female, group 3)
[The sessions] in group I think it is better. We can share our
ideas. Pains can be seen in very different ways. (Male, group 2)
Participants in group 4 suggested the use of text messages
and/or social networks to remind them to do their exercises at
home on a more regular basis, likely improving adherence.
DISCUSSION
This study explored the perceptions of adolescents with
chronic idiopathic NP toward an intervention based on pain
neuroscience education and exercises delivered at the school set-
ting. The results support consensus on the relevance and ade-
quacy of the intervention. Pain neuroscience education was per-
ceived both as a means to facilitate pain reconceptualization and
as complementary to exercise. Furthermore, pain reconceptu-
alization emerged as the basis of changes of attitude toward
pain and exercise as well as of changes in participants’ feel-
ings and behavior. Participants’ perception regarding neck and
shoulder exercises changed from a potential threat (something
that could cause damage) to something that is beneficial and
needed for recovery. This highlights the complementary role
between pain neuroscience education and exercises and gives
support to the claims in favor of combining these therapeutic
approaches.10,32 The pediatric fear-avoidance model of chronic
pain33 premise is that the response to pain is either confronta-
tion to pain and recovery or fear of pain and emotional distress,
leading to escape and avoidance behavior and, consequently, to
disability and more pain, in a vicious self-perpetuating cycle.
This study supports both the adequacy of this model for adoles-
cents with chronic NP and the use of pain neuroscience educa-
tions as a means to break the cycle.
Pain neuroscience education also had a positive effect
on self-efficacy. According to the social cognitive theory, self-
efficacy beliefs are a key element that, jointly with goals,
outcome expectations and perceived environmental barriers
and facilitators regulate action and motivation.34 Knowledge
constitutes a precondition for change, which then requires the
belief on one’s capability to change. This belief is strengthened
by several factors: the experience of peers, verbal persuasion,
reduction of stress and negative emotions, and correction of
misinterpretations regarding one’s physical state. Pain neuro-
science education in the present study was delivered in groups
and therefore could have facilitated self-efficacy through the
experience and example of peers. In addition, and in line
with the social cognitive theory, pain neuroscience education
200 Neto et al
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might have fostered self-efficacy by correcting misconceptions
regarding their NP, lowering negative emotions toward it and
helping students to manage NP.
Intervention in groups was seen as positive. This is not
consistent with the finding that for adults’ one-on-one educa-
tional sessions are associated with a more favorable outcome
when compared with educational sessions delivered in group.10
This inconsistency may be due to the importance of peer
relationships in adolescence, which may contribute to the
increased value of sharing a common experience and feeling
part of a group as adolescents with pain have been shown to
spend more time by themselves, and to feel misunderstood and
unsupported by their peers.35 Participants also suggested the
use of text messages and social networks to increase adherence
to home exercise in between sessions. The use of mobile tools
to increase patients’ adherence to physical activity has been
considered effective.36
This study results are in line with the findings of a recent
study exploring the views of adults with chronic pain toward
pain neuroscience education.37 These authors interviewed 10
adult patients (a mean age of 48 years and a mean pain dura-
tion of 9 years) who participated in a single 2-hour session of
pain neuroscience education and reported that 3 main themes
emerged from their analysis: the perceived relevance, the per-
ceived benefit, and pain reconceptualization. These themes are
well aligned with our findings. Nevertheless, Robinson et al37
reported that the positive view on pain neuroscience education
was not always shared. This contrasts with the present study
findings that all participants agreed on the relevance of pain neu-
roscience education. This contrasting result may be explained
by different sample characteristics. Participants in the present
study were younger, most of them were familiar with some of the
terminology used in pain neuroscience education from biology
classes, and had pain of a shorter duration and, perhaps, of
lower intensity. In addition, this study used focus group inter-
views while Robinson et al37 used individual interviews. While
an effort was made so that each participant could express an
opinion, we cannot exclude the possibility that some partici-
pants might have felt uncomfortable to have a divergent view.
Study Limitations and Future Work
The lead interviewer was one of the physical therapists
who administered the intervention. This could have led par-
ticipants to refrain from identifying the less positive aspects of
the intervention. Nevertheless, all members of the research team
emphasized the importance of participants’ opinions regardless
of whether they were positive or negative and the interviews
were conducted in an informal environment. Being afraid that
other students could know that they had pain and were part
of a group intervention did not arise as a concern of adoles-
cents who participated in this study. Nevertheless, this was not
directly addressed in the interview. In addition, transcripts were
not returned to participants for comment and/or correction as
recommended by COREQ,30 which would have improved the
strength of the findings.
The study results support future studies investigating the
role of pain neuroscience education delivered at early stages of
Pediatric Physical Therapy
pain, for example, studies comparing the clinical course of pain
in patients receiving and not receiving education on pain neu-
roscience, as pain catastrophizing and fear of movement have
been shown to have a crucial role in the transition from acute to
chronic pain.38,39
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