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376 Sempere-Rubio et al. | Journal of Clinical and Translational Research 2023; 9(6): 369-380
were evaluated in combination with other interventions, which compared to exercise-based intervention alone in patients with
were not present in the comparator group. chronic musculoskeletal pain [31] or in patients with chronic
non-specific spinal pain [32]. Given that exercise has already
4.1. Summary results
shown positive results in pain patients such as FMS [33,34]
Analyzing the outcome for each variable, for pain intensity, or chronic non-specific low back pain [35,36] in the scientific
we found mixed evidence in favor of HEI alone, as we found literature, it seems that future studies should address whether
significant and non-significant post-intervention results. However, HEI could improve the efficacy of therapeutic exercise-based
in the short- to medium-term, no significant differences were interventions. It is important to highlight at the clinical level
found in favor of HEI. When HEI was combined with other the dosage of HEIs in the patient with persistent pain, in this
interventions, the results showed significant effects on the case, applied to FMS. Recently, the study conducted by Salazar-
reduction of pain intensity in the short and even in the medium Méndez et al. [37] aimed to evaluate how long it is necessary
term. With respect to quality of life, HEI in isolation did not lead to perform PNE and PNpE in patients with chronic pain to
to significant improvements in the short term; however, mixed obtain a clinical change in psychosocial variables. The authors
evidence was found in the short- to medium-term. When HEI was found very interesting results. For example, they found that the
combined with other interventions, the results showed significant longer the HEIs time, the greater improvements were found
effects on improving quality of life in the short, medium, and in variables such as anxiety, catastrophizing, or movement-
even long term. On the variables functionality and anxiety, the related fear. In fact, it was estimated that a dose of 100, 200,
HEI alone did not show any significant effect on the improvement and 400 min of HEIs exceeded the clinically relevant difference
of these variables. However, when analyzing the combination of in the improvement of the three variables mentioned above.
HEI with other interventions, we found significant improvements Finally, as a practical recommendation for implementing HEI
in both functionality and anxiety symptoms in favor of HEI in patients with FMS, the authors of this article propose that
combined with other interventions. Finally, with regard to the pain HEI should be implemented in combination with other clinical
catastrophizing variable, the results showed that the HEI alone interventions (such as therapeutic exercise) to achieve a stronger
did not lead to any significant improvement. When evaluating the clinical effect. The application should be individualized and
combination of the HEI with other interventions, the evidence person-centered. Consideration should be given to the application
found was mixed. of not only educational aspects but also processes focused on
changing dysfunctional behaviors to have a greater impact on the
4.2. Strengths and weaknesses of HEIs person and be applicable to the person’s daily life. Finally, dosage

Overall, it seems that the addition of HEI to other matters and clinicians must deliver the number of sessions (or
interventions, mostly therapeutic exercise although we could intervention time) necessary to have an influence on the clinical
refer to it in terms of a multimodal approach, leads to greater variables of interest in FMS patients.
clinical improvements than HEI in isolation. We have seen this 4.3. Study limitations
especially in some clinical variables of interest such as pain
intensity or quality of life. It seems that the main strength of This review has some limitations that need to be taken into
the HEI is the interaction with other interventions to enhance its consideration. First, a great deal of heterogeneity has been
efficacy with respect to the outcomes assessed. HEI are clinical found with education models, which makes it difficult to draw
interventions that has the communication process as a key solid conclusions. Studies are needed to define well what
point of its application and where the patient feels listened to, each intervention is and how to implement it so that it has its
cared for and, in addition, allows patients to better understand own name. Second, the results were categorized into “HEI in
their clinical condition process [30]. This increased knowledge isolation” and “HEI combined with other interventions”. We
from a patient perspective, together with an adequate context included in the first those studies where only the role of HEI
promoted by empathy, shared understanding between health was evaluated or if HEI was combined with an intervention,
professional and patient, and increasing social support, seems the latter should also be in the comparator group to ensure
to help improve the influence of psychological variables that correct comparability between the groups. The group “HEI
are widely present in chronic pain processes. However, despite combined with other interventions” was created when HEI
this, a clinical approach based on HEI in isolation may be was combined with other interventions which were not found
insufficient to provide clinically relevant and meaningful in the comparison group. This is a relevant methodological
outcomes in patients with FMS, and we believe that HEI should problem because the clinical effect cannot be attributed to HEIs
be combined with an active and/or passive intervention (such completely. In addition, the quality of evidence was low for
as exercise-based interventions, manual neuro-orthopedic most of the included studies. This is an issue to be considered,
physiotherapy, or pharmacological) to improve its efficacy. as more studies in this field could probably change the results
Positive effects on decreasing pain intensity, disability levels, of the outcome measures. Future studies should ensure proper
or catastrophic thoughts have been described when researchers comparability to draw more robust conclusions. Finally, as no
combined PNE together with an exercise-based intervention statistical aggregation could be performed due to the low number
DOI: http://dx.doi.org/10.18053/jctres.09.202306.23-00108