Disability and Rehabilitation

ISSN: (Print) (Online) Journal homepage: www.tandfonline.com/journals/idre20

Pilot study on the effects of a culturally-sensitive

and standard pain neuroscience education for
Hausa-speaking patients with chronic neck pain

Naziru Bashir Mukhtar, Mira Meeus, Ceren Gursen, Jibril Mohammed, Robby
De Pauw & Barbara Cagnie

To cite this article: Naziru Bashir Mukhtar, Mira Meeus, Ceren Gursen, Jibril Mohammed,
Robby De Pauw & Barbara Cagnie (2022) Pilot study on the effects of a culturally-sensitive and
standard pain neuroscience education for Hausa-speaking patients with chronic neck pain,
Disability and Rehabilitation, 44:23, 7226-7236, DOI: 10.1080/09638288.2021.1988155

To link to this article: https://doi.org/10.1080/09638288.2021.1988155

Published online: 18 Oct 2021.

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DISABILITY AND REHABILITATION
2022, VOL. 44, NO. 23, 7226–7236
https://doi.org/10.1080/09638288.2021.1988155

RESEARCH PAPER

Pilot study on the effects of a culturally-sensitive and standard pain neuroscience

education for Hausa-speaking patients with chronic neck pain
Naziru Bashir Mukhtara,b , Mira Meeusa,c,d, Ceren Gursene , Jibril Mohammedb, Robby De Pauwa and
Barbara Cagniea
a
Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium; bDepartment of Physiotherapy, Bayero University, Kano, Nigeria;
c
Pain in Motion International Research Group (PiM), Belgium; dDepartment of Rehabilitation Sciences and Physiotherapy, University of Antwerp,
Antwerp, Belgium; eDepartment of Physiotherapy and Rehabilitation, Hacettepe University, Ankara, Turkey

ABSTRACT ARTICLE HISTORY

Purpose: To pilot feasibility and assess preliminary effectiveness of standard and culture-sensitive Pain Received 30 December 2020
Neuroscience Education (PNE) among Hausa-speaking patients with Chronic Neck Pain (CNP). Revised 14 August 2021
Methods: Adverts (online & clinic-based) were used to recruit Hausa-speaking patients with nonspecific Accepted 23 September 2021
CNP in Kano, Nigeria. Selected participants were randomized to culture-sensitive PNE (CSPNE), standard
KEYWORDS
PNE (PNE), or control groups. Each group received bi-weekly sessions of exercise therapy for 6 weeks. Pain neuroscience
Two sessions of PNE plus a home-based session were administered before exercise therapy in the PNE education; culturally-
groups. Primary (pain-intensity and disability) and secondary (pain-knowledge, pain catastrophizing, and sensitive; Hausa; chronic
quality of life) outcomes were measured. The study was pre-registered (PACTR201902788269426). neck pain; effects
Results: Fifty-three (out of 64) participants met the inclusion criteria. The majority of them were recruited
through radio adverts (83%). Interventions were successfully administered and data collection was com-
pleted for the participants. About 15% and 17% drop-out rate was recorded before intervention (post-
randomization) and during follow-up, respectively. Main results indicated that significant within-group
improvements in disability and pain knowledge scores were found in favor of the PNE groups.
Conclusion: Culture-sensitive and standard PNE plus exercise therapy are feasible for Hausa patients with
CNP, and current findings indicate support for reducing disability and increasing pain knowledge
among them.

� IMPLICATIONS FOR REHABILITATION

� Both standard PNE and culture-sensitive PNE are feasible for administration as interventions for
Hausa-speaking patients with CNP.
� Radio adverts may be necessary for patients recruitment in addition to specialists’ referrals.
� Culturally sensitive PNE materials may be more desirable as an intervention option due to the low lit-
eracy level among the Hausa population.

Introduction conclusions and/or recommendations difficult. Presently, the use

of hands-off therapies, patients education, and simple aerobic
Neck pain has been defined as pain located in the anatomical
exercises are intervention options with variable levels of evidence
region of the neck with or without radiation to the head, trunk,
that have been recommended for managing patients with non-
and upper limbs [1]. Neck pain is the fourth most common dis-
specific neck pain, especially those with normal recovery pat-
abling condition worldwide [2] and it is associated with significant
terns [8–10].
healthcare usage and expenses [3]. Over the past 28 years, neck There is increasing research interest on the importance of
pain prevalence has markedly increased and is projected to get teaching people with chronic pain how to live well with pain [11].
worse with population aging [4]. The annual prevalence of neck The use of Pain Neuroscience Education (PNE) has gained consid-
pain has been reported to be around 30% [5], with more than erable attention in both literature and clinical practice in the last
50% of individuals with acute neck pain progressing to chronic decade [12]. PNE involves teaching people in pain about the biol-
neck pain (CNP) [6]. ogy and physiology of their pain experience, including processes
Many personal and environmental factors influence the course of peripheral and central sensitization, allodynia, inhibition, facili-
and pattern of neck pain. For example, women have a higher inci- tation, and neuroplasticity [13]. PNE aims to alter maladaptive
dence of neck pain and there is an increased risk of developing pain beliefs that pain intensity is solely related to the amount of
neck pain up to 35–49 years age group, after which the risk tissue damage present. It does so by exploring the biological
begins to decline [7]. Nevertheless, substantial heterogeneity processes that underlie a disproportionate relation between tissue
among epidemiological studies exists, thereby making generalized damage and pain, as well as exploring psychosocial contributors

CONTACT Naziru Bashir Mukhtar [email protected]; [email protected] Department of Rehabilitation Sciences, Ghent University,
Corneel Heymanslaan 10, 9000, Ghent, Belgium
� 2021 Informa UK Limited, trading as Taylor & Francis Group
 PAIN NEUROSCIENCE EDUCATION FOR HAUSA PATIENTS 7227

to pain [13]. PNE provides a central explanation of how pain recruitment. Only CNP patients with a frequency of at least three
works and aims to convey common messages that can be easily days per week who fall within the age range of 18–65 years, and
understood by patients [14]. Hence, it is not surprising that PNE is are native Hausa speakers, were included in the study. In addition,
increasingly been reported to improve treatment outcomes using history and physical examination, the specialists ensured
including pain intensity, disability, pain cognitions and beliefs that only patients with normal recovery patterns based on treat-
(e.g., fear-avoidance, pain catastrophization, and impaired move- ment profile A (neck pain grade I/II, normal course), were
ment), and health care utilization in chronic pain patients [13,15]. recruited for the study [8]. Patients with hearing or a visual
Although PNE has been shown to be effective for different types impairment, previous spinal surgery, chronic joint disorders,
of musculoskeletal pain, however, only one study has highlighted neurological deficit, inflammatory or infectious diseases of the
the potential benefits of PNE and exercises in the management of spine, pregnant or other severe disabling health conditions
adolescents with chronic idiopathic neck pain [16]. Also, PNE has were excluded.
not been evaluated in adults with neck pain. Conducting a pilot study is important in health research as it
Due to the efficacy of PNE in chronic pain management provides information for planning and justifying an RCT [30]. A
[17–19], there is a need for further internationalisation of its appli- pilot study might give warning about where the main research
cation. Presently, PNE is well established (developed and vali- project could fail, where research protocols may not be followed,
dated) among Caucasians [12,15,20–23], and access to it by other or whether proposed methods or instruments are inappropriate
world languages and cultural groups is still lacking. More import- or too complicated [31]. Based on the literature reports [32,33],
antly, variations in culture, socioeconomic status, gender issues, the authors estimated a minimum sample size of 10–12 partici-
and literacy levels have to be considered when developing educa- pants (three additional participants to cover attrition) per group
tional tools for any population [24]. Patients’ beliefs are a core to be sufficient to pilot this type of study to enable the execution
part of pain perception and response, as such response to pain is of a full clinical trial in future.
often influenced both by patients’ beliefs about it and the emo- Eligible patients received information about the trial and pro-
tional significance attributed to it [25]. Moreover, a recent system- vided written informed consent. Study participants were asked to
atic review found that African-Americans tend to use more stop taking their analgesic medications and not to seek additional
prayers and hope, distraction, and catastrophizing as a coping therapy for their neck problems while participating in the study.
strategy, and also had less pain control beliefs compared to Notwithstanding, in case of an acute exacerbation of symptoms,
Caucasians [26]. the participants were allowed to use their rescue analgesics or
Until recently, neither a translated nor culturally adapted ver- any other pain medication prescribed by their physician. An inde-
sion of PNE existed for any of the indigenous African languages. pendent research assistant randomized the participants into three
Consequently, we conducted a Delphi study in which culturally groups using sealed envelopes. Since the participants for this
sensitive PNE materials were developed for African (Hausa) research were consecutively recruited, block randomization of six
patients with chronic spinal pain (CSP) [27]. Accordingly, there is participants per block was deemed suitable and used. Specifically,
now a need to evaluate the feasibility and effects of the devel- anytime a group of six consecutive participants met the inclusion
oped materials in managing these patients. This study focused on criteria, they were randomized into the three groups at the
patients with CNP because findings from a recent study recom- same time.
mended further research in this population [28]. The main aim of
this pilot study was to assess the feasibility of the recruitment/
screening procedures, the effectiveness of blinding, rate of attri- Interventions
tion, data completeness and intervention needs, and the prelimin- Template for intervention description and replication (TIDieR) cri-
ary effectiveness of the standard and culturally sensitive PNE teria for reporting of the interventions [34] was used in reporting
interventions. the interventions of this pilot study. To ensure equality in sessions
and attention, participants in each of the three groups received a
Materials and methods total of 12 therapy sessions (two sessions per week for 6 weeks)
and each session lasted for a maximum of 30 min. All the groups
Research design received exercise therapy, while the education groups received
The study is an assessor-blinded, three-arm pilot study conducted additional intensive PNE sessions, before exercise therapy, based
between March and December 2019 in two federal government on the standard recommendation [35].
hospitals in Kano state (Aminu Kano Teaching Hospital and
National Orthopaedic Hospital, Dala), Nigeria. Ethical approvals The study groups were
were obtained from the ethics and research committees of the
two hospitals. The trial was registered with the Pan African Exercise therapy, which served as the active control (CT),
Clinical Trial Registry (PACTR201902788269426) accessible from Standard-translated PNE (PNE), and Culturally sensitive PNE
https://pactr.samrc.ac.za/Search.aspx and the study is reported (CSPNE) groups.
based on the CONSORT statement extension for feasibility and The control therapy (Exercise Therapy) group had exercised
pilot studies [29]. for about 20-min circuit, which was preceded by 5 min of warm-
up consisting of walking and general stretching exercises and pro-
ceeded by 5 min of cool down (the whole session lasted for about
Participants and recruitment
30 min).
Patients with CNP were recruited from the physiotherapy and out- The general exercise training protocol was based on a modi-
patient departments of the participating hospitals. Additionally, fied back fitness manual [36]. Although the manual targets back
radio and social media adverts were utilized to invite potential pain patients, the aims of the exercises are for the overall well-
participants who were initially screened by two orthopedic spe- being of the patients and fitness of the spine and limbs. Hence, it
cialists (one from each of the two intervention centers) before was considered fit for neck pain patients. The only modification
7228 N. B. MUKHTAR ET AL.

Table 1. Exercise protocol for the warm-up, cool down, and training proper. The translated standard PNE group
S/N Duration
During the first three treatment sessions, participants in this
Warm-up and cool-down exercises
group received three sessions of PNE (two during clinic teaching
i Walking on toes or walking on heels (to be alternated from 60 s
one session to another) sessions and one using a home education leaflet). The standard
ii Taking up knees to waist height or taking heels back to touch 60 s documents (as obtained from Pain in Motion group web page:
bottom (to be alternated from one session to another) www.paininmotion.be) were translated into Hausa language based
iii Walking backwards or walking sideways (to be alternated 60 s
on the standard forward-backward translation procedure [37]
from one session to another)
iv Calf muscle stretch for left and right limbs each 20 s before the interventions. The English versions were translated to
v Shoulder girdle stretch one each for left and right 20 s Hausa independently by two native speakers of Hausa. The two
upper limbs initially translated versions were then translated back to English
vi Spinal and hip extensors stretch 20 s
by a third translator. The two translators checked the original and
vii Anterior trunk and hip flexors stretch 20 s
viii M. Rectus femoris stretch for left and right limbs 20 s the back-translated versions and came up with the Hausa stand-
Exercise (training) proper ard translated PNE materials.
i Walking on the spot to be progressed to running on the spot 60 s
and finally to running on the spot with knees high,
progression will be done at two weeks interval The culturally-sensitive PNE (CSPNE) group
ii Diagonal trunk curl to the left and right 60 s
iii Sideway steps (to the left and right) then progressing to 60 s During the first three treatment sessions, participants in this
sideways steps plus swinging arms and finally to star group received three sessions of culturally sensitive pain educa-
jumps, progression will be done at two weeks intervals tion programs for Hausa patients [27] (two clinic teaching sessions
iv Press-ups; against the wall then progressing to modified 60 s
press-ups from knees and finally to full press-ups, and one listening session using home education audio material).
progression will be done at two weeks intervals The features of the CSPNE include; limited information on pain
v Leg raise sideways for the left and right 60 s neuroscience, use of separate teaching materials for men and
vi Leg raise backwards for the left and the right 60 s women, using culture-specific metaphors, pictures, drawings, and
vii Trunk curls 60 s
viii Stands up from fundamental sitting positions with arms 60 s examples to explain pain neuroscience, and developing a home
across the chest education material in an audio form [27].
Ix Arm circling for the left and right 60 s Each of the pain education teaching sessions lasted for about
X Bridging 60 s 30 min, while reading of the home education leaflet (PNE) or the
Exercise proper numbers i, iii and iv have progression indicated while for the listening of the home education audio interview (CSPNE) is esti-
rest, patients will have their repetitions counted in each minute and they will
be encouraged to increase the repetitions over the weeks.
mated to also last for an average of 30 min. A one-on-one teach-
ing method was used for all participants in these groups. Here,
the first author sits and educates the participants individually
using the PNE PowerPoint slides. The contents of the PNE materi-
was to reduce the duration of the exercise program from 1 h per
als were maintained throughout the educational sessions, how-
session to 30 min per session (See Table 1). The reduction in dur-
ever, based on the patient’s unique situation, additional
ation was also aimed at improving compliance. The general aim
explanations that are within the PNE concept were given. The first
of exercise training is to improve physical function and increase
author who is a Hausa native-speaker and had training on pain
confidence in using the spine normally. Meanwhile, the specific
aim of the exercises is to strengthen the main muscle groups of education administered the education sessions. After the 3rd ses-
the body, including the abdominal and trunk muscles, stretching sion for both PNE and CSPNE groups, the same intervention as in
the muscle groups, and increase cardiovascular fitness through the CT group was administered from the 4th through the 12th ses-
low-impact aerobic exercises [36]. sions at a self-determined intensity by the research assistants.
All the exercises were carried out by the participants under
the guidance of trained research assistants. The research assistants Outcome measures
were four qualified physiotherapists with a minimum of one year Demographic data were collected at the start of the study, while
of clinical experience. The research assistants received two train- patient-related outcomes were assessed at different points inter-
ing sessions on how to effectively administer the exercises based vals. Figure 1 presents the levels of outcome measurements and
on the adopted template, and how to finish the training within the intervention patterns.
the specified time. Additionally, pictures of the exercise patterns
were given to the participants by the research assistants to guide Primary and secondary outcomes
them during the intervention exercises. The exercises were exe- The outcomes assessed in this study were based on the recom-
cuted in the physiotherapy gymnasium of the participat- mended outcomes for spinal pain patients [37]. Tools that are
ing hospitals. widely used in the study area and have Hausa-translated versions
After the first two sessions, each participant received the pic- were considered. Due to the lack of cross-culturally validated
tures of the exercises and they were guided on how to carry out patient outcome tools in Hausa language, two outcome tools
one additional session at home per week. Participants also had to were translated into Hausa. In the end, five tools (outcome meas-
verbally indicate whether they performed the prescribed exercise ures) were finally used for the data collection and assessment.
per week. The participants were also asked to adhere to the same These included pain intensity, and disability for the primary out-
home exercise (twice per week) after the 6 weeks treatment come of interest, whereas the quality of life, pain catastrophizing
period until the last follow-up date (3 months after the last treat- and pain knowledge as secondary outcomes. Accordingly, the
ment). Phone calls were used to remind the patients about their tools utilized were (1) the Visual Analogue Scale (VAS) for pain
home exercises. In the event the phone numbers were unavail- intensity [38], (2) a 7-item Pain Disability Index (PDI) [39], (3) a 13-
able or the call was not answered/returned, the adherence to the item Pain Catastrophization Scale (PCS) for pain catastrophizing
home exercises was checked verbally during the follow-up period. [40], (4) 36-item SF-36 for quality of life [41], and (5) the 13-item
 PAIN NEUROSCIENCE EDUCATION FOR HAUSA PATIENTS 7229

Figure 1. Flow chart of the pilot study. CSPNE: Culturally Sensitive Pain Neuroscience Education; CT: Control Therapy; PCS: Pain Catastrophizing Scale; PDI: Pain
Disability Index; PNE: Pain Neuroscience Education; RNPQ: Revised Neurophysiology of Pain Questionnaire; Rx: Treatment; SF-36: Short Form 36 questionnaire; VAS:
Visual Analogue Scale.

Revised version of Neurophysiology of Pain Questionnaire (RNPQ) participants to complete the study questionnaires. The effective-
for pain knowledge of the participants [42]. ness of assessor blinding was done by asking the assessors at
The translated and cross-culturally adapted Hausa versions of pre-intervention, post-intervention, and follow-up about the
PCS (concurrent validity of 83% and Cronbach’s a of 0.84 for groups of the participants. Since participants were not aware of
internal consistency) [43] and SF-36 [44] already existed and were the official name of the groups they belong, the chance of reveal-
used, while PDI and RNPQ were translated into Hausa using the ing group names to assessors during data collection was mini-
standard forward-backward procedure earlier described [45]. All mized. Participants receiving culture-sensitive or standard PNE
outcome measures were assessed at baseline, post-intervention were also blinded to group allocation. Similarly, the data analyst
(at 6th week), and follow-up (at 3 months). In addition, pain know- was also blinded to the group allocation, by anonymizing the
ledge was evaluated after the 3rd session of PNE/exercise therapy. groups, until after all data analyses were completed.

Blinding Data analysis

Assessment of all outcomes was carried out by two research assis- Based on the understanding that this study is not statistically
tants (assessors) that were blinded to the group allocation of par- powered to detect significant differences between the groups,
ticipants throughout the study. They assisted the non-literate hence a time-point analysis was carried out. However, between-
7230 N. B. MUKHTAR ET AL.

Table 2. Participants’ demographics and baseline comparisons.

PNE (n ¼ 15) Lost to follow-up CSPNE (n ¼ 17) Lost to follow-up CT (n ¼ 13) Lost to follow-up
n (%) n (%) n (%) pa
Gender
Male 7 (41) 1 (20) 10 (67) 2 (100) 10 (76) – 0.116
Female 10 (59) 4 (80) 5 (33) – 3 (23) 1 (100)
Educational status (school)
Islamiyah 1 (6) 1 (20) 3 (20) – 0 (0) – 0.159
Primary 7 (41) 2 (30) 7 (47) – 3 (23) –
Secondary 0 (0) 2 (40) 1 (7) 1 (50) 2 (15) –
Tertiary 6 (35) – 0 (0) – 4 (31) 1 (100)
University 3 (18) – 4 (27) 1 (50) 4 (31)
Primary occupation
Business 8 (47.0) 3 (60) 6 (40) 1 (50) 4 (30.7) –
Civil servant 1 (5.9) – 2 (13.3) 1 (50) 3 (23.1) –
Farming 1 (5.9) – 0 (0) – 0 (0) –
House-wife 2 (11.8) 1 (20) 1 (6.7) – 0 (0) –
Security 0 (0) – 1 (6.7) – 0 (0) –
Student 1 (5.9) – 0 (0) – 2 (15.4) 1 (100)
Tailoring 2 (11.8) 1 (20) 4 (26.6) – 3 (23.1) –
Teaching 2 (11.8) – 0 (0) – 1 (7.7) –
Unemployed 0 (0) – 1 (6.7) – 0 (0) –
Marital status
Married 11 (64.7) 3 (60) 11 (73.3) 1 (50) 6 (46.2) – 0.380
Single 5 (29.4) 1 (20) 3 (20) 1 (50) 6 (46.2) 1 (100)
Widow 1 (5.9) 1 (20) 1 (6.7) – 1 (7.6) –
Mean (SD) Mean (SD) Mean (SD) pa
Age 36.4 (14.16) 39.3 (12.17) 31.2 (10.40) 0.235
(years)
BMI 22.6 (4.91) 23.7 (4.60) 22.1 (6.75) 0.280
(kg/m2)
VAS 7.0 (2.09) 6.1 (2.24) 6.5 (2.69) 0.415
PDI 4.2 (3.11) 3.3 (2.49) 3.8 (2.62) 0.701
PNE: Standard Pain neuroscience Education; CSPNE: Culturally Sensitive Pain Neuroscience Education; CT: Control; BMI: Body Mass Index; PDI: Pain
Disability Index; VAS: Visual Analogue Scale.
a
p value obtained from Chi-square.

group analyses for the baseline data were carried out to ensure recruitment procedure lasted for five months (March 2019 to July
comparability of the groups. 2019) with 4 weeks devoid of new participants that coincided
All data were analyzed using R, version 4.0.1 (R Core Team, with the Islamic month of Ramadhan (fasting period). Two special-
2020). Categorical baseline biodata of the participants was com- ists were able to successfully screen all the prospective partici-
pared using Chi-square test with simulated p-values, while the pants within the recruitment period. No hindrance to screening
continuous baseline biodata was analyzed using Kruskal-Wallis was reported by any of the specialists.
test due to the non-normality of data. Comparability among the
included groups for baseline outcome data was evaluated by a
Mann-Whitney U test due to violations on within-group normality Effectiveness of blinding
of data or between-group differences invariances. To assess the
Assessors were blinded in the study and both assessors
difference between time-points (baseline, post-intervention, and
3 months follow-up) and treatment groups (CSPNE, PNE, and CT) responded with “I don’t know” to the question on whether they
in response to treatment, a random-intercept linear mixed model knew the group of the participants. The only additional informa-
(3 � 3) was applied. The model included treatment, time, and tion they gave was knowing the anonymized tag used for each
treatment � time as fixed effects together with a random inter- group (NAL, RAL, TED) without knowing their meaning. The data
cept for each patient. The model fixed effect parameters were analyst was also successfully blinded using the anonymized tags.
evaluated with Satterthwaite’s method [46,47]. Estimated marginal
means were calculated and tested using Bonferroni post hoc anal-
yses, as implemented in the package “emmeans” [47]. Effect sizes Rate of attrition
of the meantime differences were calculated as the Cohens D. A total of 17, 18, and 18 participants were randomized to receive
p < 0.05 (2-sided) was considered significant. The effect size was CT, CSPNE, and PNE interventions, respectively. Before the com-
categorized as; >0.8 (large effect size), between 0.5 and 0.8 mencement of all treatments, 4, 3, and 1 participants dropped
(medium effect size) and <0.5 (small effect size). out from CT, CSPNE, and PNE groups respectively. During the six-
week intervention period, no dropout was recorded, while 1, 2,
Results and 5 participants were lost to follow-up (3-month post-interven-
tion) in the CT, CSPNE, and PNE groups, respectively. The dropout
Feasibility of the recruitment/screening procedures
in the CT group before the commencement of the intervention
Recruitment of the participants was feasible when specialists’ (24% dropout rate) and the loss to follow-up in the PNE group
referral was combined with Radio and social media adverts. The (28% dropout rate) is on the high side (see Figure 1).
 PAIN NEUROSCIENCE EDUCATION FOR HAUSA PATIENTS 7231

Table 3. Overview of primary and secondary outcomes.

Estimated marginal means (SE) Main effect of time
Groups Post hoc tests for time
Primary outcomes T0 T1 T2 F pa Comparison ES P
VAS 65.30 <0.001�
CT 6.50 (0.61) 3.69 (0.61) 4.11 (0.63) T0–T1 1.64 <0.001*
T0–T2 1.39 0.002*
T1–T2 0.24 0.999
CSPNE 6.12 (0.57) 2.59 (0.57) 2.49 (0.60) T0–T1 2.06 <0.001*
T0–T2 2.12 <0.001*
T1–T2 0.06 0.999
PNE 6.93 (0.53) 2.22 (0.53) 1.99 (0.62) T0–T1 2.74 <0.001*
T0–T2 2.88 <0.001*
T1–T2 0.14 0.999
PDI 12.69 <0.001�
CT 3.77 (0.66) 2.15 (0.66) 2.22 (0.68) T0–T1 0.87 0.090
T0–T2 0.83 0.126
T1–T2 0.04 0.999
CSPNE 3.27 (0.61) 1.60 (0.61) 2.76 (0.65) T0–T1 0.90 0.049*
T0–T2 0.27 0.999
T1–T2 0.62 0.322
PNE 4.18 (0.58) 1.76 (0.58) 1.71 (0.67) T0–T1 1.30 <0.001*
T0–T2 1.33 0.003*
T1––T2 0.03 0.999
Secondary outcomes 36.56 <0.001�
SF 36
CT 51.1 (4.6) 69.8 (4.6) 71.9 (4.7) T0–T1 1.40 0.002*
T0–T2 1.56 <0.001*
T1–T2 0.15 0.999
CSPNE 57.9 (4.2) 81.5 (4.2) 70.6 (4.5) T0–T1 1.77 <0.001*
T0–T2 0.95 0.045*
T1–T2 0.81 0.111
PNE 46.2 (4.0) 68.4 (4.0) 76.4 (4.7) T0–T1 1.66 <0.001*
T0–T2 2.26 <0.001*
T1–T2 0.61 0.999
PCS 39.00 <0.001�
CT 28.9 (2.9) 18.8 (2.9) 15.7 (3.0) T0–T1 1.19 0.010*
T0–T2 1.57 <0.001*
T1–T2 0.38 0.999
CSPNE 27.5 (2.7) 13.3 (2.7) 11.9 (2.9) T0–T1 1.68 <0.001*
T0–T2 1.84 <0.001*
T1–T2 0.16 0.999
PNE 35.5 (2.5) 22.4 (2.5) 18.2 (3.0) T0–T1 1.55 <0.001*
T0–T2 2.05 <0.001*
S1 S2 S3 S4 F pa Points ES p
RNPQ 10.81 <0.001� S1–S2 0.43 0.999
CT 4.2 (0.43) 4.9 (0.43) 5.0 (0.43) 4.1 (0.45) S1–S3 0.54 0.999
S1–S4 0.13 0.999
S2 –S3 0.11 0.999
S2–S4 0.56 0.991
S3–S4 0.67 0.590
CSPNE 4.5 (0.40) 6.7 (0.40) 5.9 (0.40) 5.6 (0.43) S1–S2 1.55 <0.001*
S1–S3 0.94 0.068
S1–S4 0.72 0.366
S2 –S3 0.61 0.583
S2–S4 0.83 0.188
S3–S4 0.22 0.999
PNE 3.7 (0.38) 5.7 (0.38) 5.1 (0.38) 4.8 (0.45) S1–S2 1.45 <0.001*
S1–S3 1.04 0.019*
S1–S4 0.78 0.256
S2–S3 0.41 0.999
S2–S4 0.67 0.494
S3–S4 0.25 0.999
PNE: Standard Pain Neuroscience Education; CSPNE: Culturally Sensitive Pain Neuroscience Education; CT: Control; PDI: Pain Disability Index; VAS: Visual Analogue
Scale; PCS: Pain Catastrophizing Scale; RNPQ: Revised Neurophysiology of Pain Questionnaire; ES: Effect Size; T0 ¼ Baseline, T1 ¼ Post-intervention, T2 ¼ Follow-up,
S1 ¼ Baseline, S2 ¼ Immediately after the 3rd session, S3 ¼ Post-intervention, S4 ¼ Follow-up.
�p < 0.05, ap value obtained from 3 � 3 two way ANOVA test.

Exercise adherence Preliminary outcomes

Checking the exercise adherence during the follow-up period was A total of 64 participants were screened out of which 55 met the
unsuccessful, as the phone call reminder method proved unreliable, inclusion criteria (see the recruitment and participation flow in
and some participants who did not show up during intervention Figure 1). Eleven participants that were excluded have pains in
sessions did not respond to/return phone calls made to them. the frontal region of the neck (tonsillitis, goiter, sore throat, etc.)
7232 N. B. MUKHTAR ET AL.

and or serious psychosocial issues based on the specialists’ interacting with the participants, we realized the Hausa word
screening. Therefore, a total of 45 participants completed the six- used in the Radio and social media adverts to refer to neck pain
weeks intervention with 37 participants completing the follow-up (ciwon wuya) is a generic term and it can be misunderstood as
stage of the study. The characteristics and baseline comparisons referring to ailments related to the structures of either the back
of the participants are presented in Table 2. There were more or the front of the neck. Subsequent adverts should use a specific
male participants in the CT and CSPNE groups compared with the word that will denote pain in the back of the neck area.
PNE group. All groups were comparable in their mean age, mari- Only CNP patients with treatment profile A were recruited
tal status, gender, BMI scores, and educational status and also in because aerobic exercise that was performed by all participants is
the baseline mean scores of the primary outcome measures (pain recommended for only patients that fall within the treatment pro-
intensity and disability). file [8]. Care has to be taken in recruiting patients outside this
Figure 1 presents the flow chart for the study recruitment, allo- profile during the conduct of a full RCT or other subsequent stud-
cations/groupings, level of measurements, outcome measures, fre- ies unless other clinical guidelines/recommendations are followed.
quency/duration of interventions, and dropouts. Only 11 (24%) of the participants in this study have attained a
Table 3 overviews the results of this pilot study for VAS, PDI, university-level education, which reflects the low literacy level
SF-36, and PCS at all three levels of measurement, and RNPQ at among the population. A substantially higher number of 21 (47%)
four levels of measurement. The table shows that no interaction out of the total number of the participants had a maximum of
effects were identified as significant, indicating the lack of primary school education, which may not be enough for them to
between-group differences within each of the time points. read and write in the Hausa language as observed during the
However, for each of the primary and secondary end-points, a sig- data collection. Moreover, low literacy levels have been previously
nificant main effect of time was identified. There were statistically reported [51], and are still a major problem in the study area
significant within-group improvements in favor of the education (Northern part of Nigeria) where Hausa people are predominantly
groups for pain disability (SPNE; p < 0.001 at post-intervention domiciled. Although the present study considered the low literacy
and p ¼ 0.003 at follow-up and CSPNE; p ¼ 0.049 at post-interven- level during the tool development and in this pilot, there may be
tion). Significant improvement in RNPQ was only noticed immedi- a need for additional educational sessions as against the few
ately after intervention for the education groups (SPNE; p < 0.001 (2–3) sessions used in this study. This is important for a better
at the immediate level and p ¼ 0.019 at post-intervention, and understanding of the pain concepts. Furthermore, previous stud-
CSPNE; p < 0.001 at immediate level). ies have reported that non-literates perform poorly in interven-
tions requiring educational sessions [52]. However, frequent
Discussion repetitions of the concepts have been found to improve memory
among non-literates [53]. Another important area is in the use of
To the best of our knowledge, this is the first study piloting the
group sessions, which have been advocated for teaching PNE
feasibility of administering standard or culture-sensitive PNE in
[54]. In this study, we used a one-on-one teaching method due to
African patients with chronic pain. The aim of this pilot study was
the varying literacy level of the participants to allow for an indi-
to assess the feasibility of the recruitment/screening procedures,
vidualized pace in teaching and learning for the participants.
the effectiveness of blinding, rate of attrition, data completeness,
Moreover, the participants came at different times irrespective of
and intervention needs, and to also assess the preliminary effect-
their appointment, which also makes groups sessions
iveness of the standard and culturally sensitive PNE interventions.
Participants of the present study were recruited through; a dir- impracticable.
ect referral to physiotherapy by either a specialist, social media During the interventions and outcome measurements, partici-
advert (Facebook(R)) and/or via a popular Radio (FM) announce- pants cooperated and participated fully in all the sessions.
ment in the study area. A similar recruitment procedure has been Blinding of outcome assessment was successful as well, and no
employed by a previous PNE study among Nepali patients [48], case of intervention-related adverse reactions was recorded. These
which reported a lower response rate through similar adverts are positive factors that support the possibility of conducting a
(30%). Surprisingly, in this study, fifty-three interested participants full RCT.
(83%) were obtained via the FM Radio advert (Figure 1). This por- This study recorded some dropouts at various stages (reasons
trays the importance of using radio for the recruitment of partici- presented in Figure 1). Eight out of 53 (15%) dropped out before
pants in the study setting (Hausa-land). Additionally, prospective the start of the intervention after being randomized into groups.
participants were informed during the adverts that they will be Contrastingly, no dropout was recorded during the 6-weeks inter-
managed free of charge. This may have motivated the intending vention across the groups, while eight participants (17%) were
participants since many patients in the study area are known to lost to follow up. The PNE group accounted for a higher dropout
stay at home without seeking medical attention for several ail- at follow-up (11%). Notwithstanding, the dropout rate in this
ments to avoid hospital costs due to high poverty rates in the study is lower than those reported (29%) in previous pilot PNE
region [49,50]. studies for Turkish immigrants in Belgium [55] but higher than
The five months spent to recruit participants of this study, those reported (5%) in a feasibility PNE study among Nepali
though successful, may be considered long when conducting a patients [48] with spinal pain (LBP). However, the average follow-
study with a larger sample size. We limited our advert to only up duration for the Nepali patients was 7-days, which might have
one FM radio station and a few adverts per week due to lack of contributed to the lower dropout rates. This finding is not surpris-
funding. This can be overcome by employing different Radio sta- ing because high dropout rates have been identified as a feature
tions to advertise recruitment for the study to get a larger num- of patients undergoing rehabilitation [56]. Another reason for the
ber of participants in a short time. high dropout rate among Turkish immigrants may be because the
During the recruitment process, 11 prospective participants study employed the use of PNE as a standalone treatment, which
that were excluded majorly presented with conditions that are is discouraged because it is considered inadequate to offer the
not similar to neck pain (goiter, tonsillitis, sore throat, etc.). While desired treatment outcomes [57,58].
 PAIN NEUROSCIENCE EDUCATION FOR HAUSA PATIENTS 7233

All the groups (including the control) showed statistically sig- questionnaires was not recorded. Most of the participants were
nificant improvements in pain intensity, quality of life, and pain recruited via radio advert (jingles). Although they were screened
catastrophizing at post-intervention (6 weeks) and follow-up by a specialist, it may be possible that some patients were only
(3 months) when compared to the baseline. This result is indica- motivated by the free-treatment advert, and they may have given
tive of the effectiveness of exercise therapy (which was given to false information to satisfy the recruitment criteria. Secondly, both
all groups) in the management of spinal (neck) pain, which is also the culture-sensitive and standard PNE sessions were administered
supported by recent systematic reviews [59–61]. by the first author (NBM), and this was only because of a lack of
This study also found a significant short-term within-group physiotherapists with expertise on PNE in the study area.
improvement for disability in both educational groups, but not in Nevertheless, NBM was blinded from the outcome assessments
the control group. This finding is supported by a recent study and data analysis. It is also possible that the potential effects of
where disability was improved in PNE combined with cognition- PNE seen in this pilot may be related to the charisma and expert-
targeted motor control training when compared to the control ise of the first author providing the educational sessions and this
among individuals with chronic spinal pain [54]. As previously could, in turn, affect generalizability. Thirdly, though the standard
mentioned, studies investigating the effects of PNE among neck PNE materials, RNPQ, and PDI used for data collection were trans-
pain patients are lacking [28], thereby limiting comparison with lated into Hausa using a recommended procedure, the translated
available neck pain studies. A Previous pilot study among Turkish materials were not validated. But this is unlikely to alter the find-
immigrants reported improvement in disability, however, this ing of the study since the questionnaires were used for all the
study was among patients with low back pain (LBP) and lacked a groups. The culture-sensitive PNE material used in the experimen-
control group [55]. The PNE group in this study sustained the tal group is yet to be validated, which makes it comparable with
improvements in disability scores even at the follow-up level the standard translated PNE materials at this stage. Nevertheless,
(3 months after), which was not observed in the CSPNE group. standard procedures were followed in developing the materials.
Coincidentally, SPNE group had a majority (59%) of female partici- The data of the participants that did not participate in the
pants as opposed to 33% female composition for CSPNE group. It intervention phase were not preserved by the research assistant
is possible that these gender variations may have contributed to and therefore we could not include their data in the analysis. A
these findings despite the lack of statistically significant differ- full RCT may do this to make predictive findings. Also, a substan-
ence. A previous study has found women to improve more in tial number of the participants in the SPNE group do not have
pain-related disabilities in daily life than men [62]. Moreover, sufficient education to read the home education leaflet provided
females are known to exhibit more coping strategies and engage on their own. However, they were instructed to get a family
in more activities with less kinesiophobia compared to males [63]. member or a friend that will read the leaflet for them.
Pain knowledge was found to be low across all the groups. Unfortunately, we could not independently verify whether this
Pain knowledge, though not frequently reported in previous stud- may have contaminated the results thereby leading to
ies, needs to be measured and improved upon due to the overestimation.
reported low levels of neurophysiological pain knowledge among Due to the unreliability of using phone calls to ensure exercise
chronic musculoskeletal pain patients [64]. The results of this pilot adherence among the study participants, simple patients diaries
corroborates these findings. Clinicians have been encouraged to that can be used by both literates and the non-literates may be
improve the knowledge of the pain physiology of their patients considered for the full RCT, since it may offer a better reminder
because it may assist in pain management [65]. A previous study option for these patients.
has reported a higher baseline mean score of pain knowledge Lastly, the data collection span for a period that included the
among first-generation Turkish immigrants in Belgium when com- Ramadhan (the fasting month for Muslim faithful) period. As a
pared to the findings of this study [55]. This finding is important result, some participants were reluctant to give their consent to
because there are no available PNE studies that have assessed participate in the study. And this led to a period of one month
pain knowledge using RNPQ among neck pain patients. The low without recruiting new participants during this pilot.
pain knowledge score may be connected with the overall low lit-
eracy level among Hausa people as previously reported [51]. The Clinical implication
highest improvement in pain knowledge was noticed in the This pilot study, confirms the feasibility for recruitment, interven-
CSPNE group. This may be as a result of the explanation that tion, and outcome measurements for both standard PNE and cul-
patients receive during culturally sensitive PNE intervention lead- ture-sensitive PNE among Hausa patients with CNP. It also permits
ing to a better understanding of the concepts, compared to those the conduct of a full RCT on the effectiveness of both standard
that received only the standard translated method. A similar trend PNE and culture PNE for Hausa patients with CNP. The study also
was also found in a recent PNE study [55]. showed that culturally sensitive PNE materials maybe more desir-
able as an intervention option, due to the low literacy level
among the Hausa population. Further, the use of a home educa-
Limitations
tion audio for the culturally sensitive PNE, which does not require
Being a pilot study, a lot of limitations are expected, which should any literacy level or assistance as opposed to the standard trans-
be addressed in the full RCT in the future. Hence, care has to be lated PNE materials that have a home education leaflet that
taken while interpreting the findings. Although we recorded the requires literacy level to read or an assistant, is necessary. Factors
educational level of the participants at the inception of the study, related to the recruitment, dropout, and period of data collection
we, however, realized that their educational levels do not trans- as reported by this study should be considered while designing a
late to their literacy level. Some participants with a supposedly full RCT.
high educational level still required assistance with questionnaire
administration, while some participants with lower educational Recommendation
levels were able to self-administer questionnaires. Unfortunately, A future full RCT with adequate sample size is recommended to
the number of participants that require verbal administration of test the effectiveness of both the culturally sensitive and
7234 N. B. MUKHTAR ET AL.

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