Pain Neuroscience Education and Neuromuscular Exercise in Individuals With Chronic Low Back Pain and Central Sensitization

The Central Sensitization Inventory (CSI) will be used to assess central sensitization symptoms. Part A consists of 25 items scored on a 5-point Likert scale, yielding a total score of 0-100. Higher scores indicate more severe symptoms.

Pressure pain threshold (PPT) will be measured using a pressure algometer at the thumbnail of the dominant hand and the L5-S1 intervertebral region. A 1-cm² probe will be applied perpendicular to the skin at a rate of 0.5 kg/s until pain is first perceived. Three measurements will be taken at 30-second intervals at each site, and the mean will be recorded.

Conditioned Pain Modulation (CPM) will be assessed using an ischemic conditioning stimulus induced by cuff inflation to 260 mmHg on the non-dominant arm, combined with wrist exercises using 1 kg for women and 2 kg for men. Exercise will continue for up to 45 repetitions or until arm pain reaches 7 out of 10. PPT will be measured three times at the thumbnail and L5-S1 region before and immediately after conditioning. CPM will be calculated as the difference between post- and pre-conditioning PPT values.

Temporal Summation (TS) will be assessed using a pressure algometer with a 1 cm² probe. Ten consecutive pressure stimuli will be applied at the PPT level to the previously tested sites, with 1-second intervals between stimuli. Pain intensity after the first and tenth stimuli will be rated using a 100-mm VAS. The TS score will be calculated as the difference between the tenth and first VAS scores (post-pre).

Revised Neurophysiology of Pain Questionnaire (RNPQ) assesses knowledge of pain neurophysiology and consists of 12 items. Correct answers receive 1 point, while incorrect and "undecided" responses receive 0 points. Total scores range from 0 to 12, with higher scores indicating greater knowledge of pain neurophysiology.

Tampa Scale for Kinesiophobia (TSK) assesses fear of movement and consists of 17 items rated on a 4-point Likert scale, ranging from 1 (strongly disagree) to 4 (strongly agree). Items 4, 8, 12, and 16 are reverse-scored before calculating the total score, which ranges from 17 to 68. Higher scores indicate greater kinesiophobia.

Pain Catastrophizing Scale (PCS) assesses negative thoughts and feelings related to pain and consists of 13 items rated on a 5-point scale from 0 (not at all) to 4 (all the time). Total scores range from 0 to 52, with higher scores indicating greater pain catastrophizing.

Fremantle Back Awareness Questionnaire (FreBAQ) assesses perceptual body awareness of the lower back and consists of 9 items covering neglect-like symptoms, reduced proprioceptive acuity, and perceived body shape and size. Items are rated on a 5-point Likert scale from 0 (never) to 4 (always), yielding a total score of 0-36. Higher scores indicate greater disturbances in back-specific body awareness.

Oswestry Disability Index (ODI) assesses disability related to low back pain and consists of 10 sections. Each section is scored from 0 to 5, yielding a total score of 0-50. The total score may be multiplied by two to express disability as a percentage (0-100%). Higher scores indicate greater disability.

30-Second Sit-to-Stand Test (30 s- STS) assesses functional lower-extremity performance. Participants sit in a chair with their feet flat on the floor and arms crossed over the chest. They are instructed to perform as many sit-to-stand repetitions as possible within 30 seconds. The number of completed repetitions is recorded, with higher scores indicating better functional performance.

Spinal posture and mobility will be assessed using the computer-assisted, non-invasive Hocoma-Valedo®Shape device (Idiag, Fehraltorf, Switzerland). Assessments will be performed with participants standing, with the spinous processes from C7 to S3 marked using a pen. Measurements will be obtained in upright standing, maximum trunk flexion, maximum trunk extension, and maximum right and left lateral flexion positions. The device will be moved along the spine from C7 to S3, tracking the marked spinous processes. Thoracic, lumbar, sacral, and inclination angles will be calculated using the device software. Spinal mobility will be calculated as the difference between maximum flexion and extension in the sagittal plane and between maximum right and left lateral flexion in the frontal plane.

Trunk muscle endurance will be assessed using the McGill test battery, consisting of trunk flexor, right and left lateral trunk, and trunk extensor endurance tests. The duration for which each position is maintained will be recorded in seconds, with longer times indicating greater trunk muscle endurance.

Balance will be assessed using the ProKin 252 system (Tecnobody, Dalmine, Italy), including static balance with eyes open and closed and limits of stability. Static balance will be assessed over 30 seconds, recording anteroposterior and mediolateral sway (mm) and the balance index (mm²). Limits of stability will be assessed by weight shifting in eight directions, with results expressed as percentages.

Sleep quality will be assessed using the Single-Item Sleep Quality Scale, a self-administered visual analog scale ranging from 0 (terrible) to 10 (excellent), evaluating overall sleep quality over the previous seven days. Higher scores indicate better sleep quality.