Pain Neuroscience Education to Reduce Catastrophizing: A Parallel Randomized Trial in Youth Athletes

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

I appreciate the opportunity to review this interesting article. It is a prospective, randomized study examining the effect of pain neuroscience education on reducing catastrophizing in athletes. Overall, I find the study well-founded and well-described. The introduction justifies the study's focus and provides relevant, up-to-date information. The methods are described in sufficient detail. The results are presented clearly. The discussion compares the present study with previous similar studies and thoroughly analyzes the obtained results and their limitations. The conclusions are appropriate and consistent with the results. I have two observations:
First, in the Methods section, it is important to specify the formula used for the sample size. Typically, online applications include the references used for the type of calculation performed. Therefore, the formula used by the application to perform the calculation should be indicated, not only the information used for the calculation.
In Table 2, it is important to include the exact values of the effect size, regardless of significance.

Author Response

Dear Reviewer,

Thank you for your helpful comments and suggestions to improve our manuscript, now entitled: “Pain Neuroscience Education to Reduce the Catastrophizing: A Parallel Randomized Trial in Youth Athletes”.

Authors are very grateful for the useful comments and time spent. Our manuscript has been substantially improved thanks to this review. The modifications are in red and bold format in the manuscript. The replies to comments are included just below everyone in bold format.

We thank you for your consideration and hope that our responses will come up to your expectations.

Yours sincerely,

 

The authors

REVIEWER 1

I appreciate the opportunity to review this interesting article. It is a prospective, randomized study examining the effect of pain neuroscience education on reducing catastrophizing in athletes. Overall, I find the study well-founded and well-described.

The introduction justifies the study's focus and provides relevant, up-to-date information. The methods are described in sufficient detail. The results are presented clearly. The discussion compares the present study with previous similar studies and thoroughly analyzes the obtained results and their limitations. The conclusions are appropriate and consistent with the results.

We are grateful for the recognition of the study’s relevance and appreciate the constructive comments.

I have two observations:

First, in the Methods section, it is important to specify the formula used for the sample size. Typically, online applications include the references used for the type of calculation performed. Therefore, the formula used by the application to perform the calculation should be indicated, not only the information used for the calculation.

According to the recommendation, we have updated the manuscript to include the formula used by the application for the sample size estimation (lines 113 – 117).

In Table 2, it is important to include the exact values of the effect size, regardless of significance.

The exact values of the effect size have been added to the Table 2.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

In this article, authors demonstrated that explanation of factors generating pain can reduce the perception and influence of pain , especially in young male athletes, even if young women athletes had a higher helplessness and catastrophism score than male athletes. Authors used a specific scale to assess components: catastrophism, rumination, helplessness and magnification.  Beautiful work. Clear tables. Clear explanation.

-In references, there are 20 recent titles, out of 51, which is good. Well chosen titles.

-in Discussion, in line 244, in “This suggests that our study may have had a limited the margin for improvement.”, please remove either “a” or “the”.

Author Response

Dear Reviewer,

Thank you for your helpful comments and suggestions to improve our manuscript, now entitled: “Pain Neuroscience Education to Reduce the Catastrophizing: A Parallel Randomized Trial in Youth Athletes”.

Authors are very grateful for the useful comments and time spent. Our manuscript has been substantially improved thanks to this review. All modifications have been highlighted in bold red in the revised version. In this response letter, we have addressed each of your comments individually, with our replies provided directly below each point, in bold format.

We appreciate your consideration and hope that our responses meet your expectations.

Yours sincerely,

 

The authors

REVIEWER 2

In this article, authors demonstrated that explanation of factors generating pain can reduce the perception and influence of pain , especially in young male athletes, even if young women athletes had a higher helplessness and catastrophism score than male athletes. Authors used a specific scale to assess components: catastrophism, rumination, helplessness and magnification.  Beautiful work. Clear tables. Clear explanation.

We are grateful for the recognition of the study’s relevance, and we appreciate the constructive and supportive comments.

-In references, there are 20 recent titles, out of 51, which is good. Well chosen titles.

Thank you.

-in Discussion, in line 244, in “This suggests that our study may have had a limited the margin for improvement.”, please remove either “a” or “the”.

Removed.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Editor and authors,

Thank you for the opportunity to review this manuscript. The study addresses a relevant and timely topic in sports science, applying a randomized design to explore pain neuroscience education in youth athletes. Below, I outlined specific suggestions.

 

Page 1, Lines 1–3: The title “Pain Neuroscience Education to Reduce the Catastrophizing of Athletes: An Experimental Study” does not specify that this is a parallel randomized trial. Suggest revising to: “…A Parallel Randomized Trial in Youth Athletes” 

Page 1, Lines 11–26 (Abstract): I recommend inserting “registered at ClinicalTrials.gov (NCT05645562), conducted at a high-performance sports center”.
Statistical outcomes are presented, but confidence intervals are missing for main results,  including both effect size and 95% CI in the abstract for transparency. The term “may reduce” is cautious but should be linked to statistical evidence and limitations in the conclusion of the abstract.

Page 1, Lines 29–41: The introduction is clear but could integrate epidemiological data specific to youth athletes earlier, as most prevalence data cited (L48–49) refers to mixed or elite adult populations. At L37–41, central sensitization is mentioned but not clearly linked to catastrophizing in healthy youth. This connection should be made explicit to justify the intervention in a non-injured sample.

Page 2, Lines 79–90: The section on sex differences states “to the authors’ knowledge…” - introduce a  brief search strategy or key citations to justify the novelty claim.

Page 3, Lines 99–109 (Design): Although trial registration and ethics approval are reported, the randomization process lacks detail on sequence generation and allocation concealment (e.g., method used by third person to assign groups beyond “OxMaR software”). Clarify whether stratification by sex or sport type occurred.

Page 3, Lines 110–116 (Sample size): Provide assumptions justification: effect size choice (3.5 PCS points), clinical relevance, and whether this is the minimal clinically important difference (MCID).

Page 3–4, Lines 125–131 (Blinding): Specify how participants were masked to the intervention's aims (if at all)—important for behavioral interventions. Report whether the outcome assessors were blinded to pre/post timing in addition to group allocation.

Page 4, Lines 149–152 (Injury registration): Describe injury classification criteria from the Oslo questionnaire (time-loss vs medical attention injuries) to ensure reproducibility.

Page 4, Lines 153–165 (Educational program): Provide content validation process for PNE material; was it piloted or reviewed by experts before delivery?

Page 4, Lines 166–181 (Statistical analysis): Report handling of missing data and dropouts in analysis, specifying whether intention-to-treat (ITT) or per-protocol analysis was used.

Page 5, Lines 182–184: Flow diagram is present but lacks detailed numbers for exclusions and reasons.

Page 5, Lines 193–194 (Table 1): Check inconsistencies in height units for IG female athletes, likely typo: “172.22” instead of “1.72 m”.

Page 5–6, Lines 197–206: Between-group non-significance is mentioned, but effect sizes and 95% CIs for these null results should be reported to aid interpretation.

Page 6, Lines 210–212: The finding of higher helplessness in females is important but underemphasized, suggest including it in the abstract.

Page 7, Lines 217–226: The opening paragraph restates results but should also quantify changes for context (e.g., “mean reduction of 2 PCS points in IG males”).

Page 7, Lines 240–245: The explanation for null between-group differences (“low baseline catastrophizing”) should be supported by reporting baseline mean values in this section.

Page 8, Lines 248–260: Sex-specific cultural factors are discussed but no direct evidence from this study is presented; recommend citing qualitative or survey data if available, or acknowledging this as speculative.

Page 8, Lines 262–267: Injury multifactoriality is acknowledged but could integrate a brief comment on whether monitoring of load or fatigue could be added in future designs.

Page 9, Lines 288–297: Good coverage of limitations, but should explicitly mention lack of follow-up period to assess sustainability of effects, key for behavioral interventions. Should also state potential Hawthorne effect due to repeated questionnaire contact.

Page 10, Lines 321–324: Funding statement says “no external funding”, but should clarify whether in-kind support (venue, staff salaries) from the High-Performance Sport Center influenced study design or conduct.

Comments on the Quality of English Language

Quality of English Language - Some sentences are long and could be simplified. Minor grammar adjustments would improve readability.

Author Response

Dear Reviewer,

Thank you for your helpful comments and suggestions to improve our manuscript, now entitled: “Pain Neuroscience Education to Reduce the Catastrophizing: A Parallel Randomized Trial in Youth Athletes”.

Authors are very grateful for the useful comments and time spent. Our manuscript has been substantially improved thanks to this review. All modifications have been highlighted in bold red in the revised version. In this response letter, we have addressed each of your comments individually, with our replies provided directly below each point, in bold format.

We appreciate your consideration and hope that our responses meet your expectations.

Yours sincerely,

 

The authors

REVIEWER 3

Dear Editor and authors,

Thank you for the opportunity to review this manuscript. The study addresses a relevant and timely topic in sports science, applying a randomized design to explore pain neuroscience education in youth athletes. Below, I outlined specific suggestions.

We are grateful for the recognition of the study’s relevance, and we appreciate the constructive comments.

 Page 1, Lines 1–3: The title “Pain Neuroscience Education to Reduce the Catastrophizing of Athletes: An Experimental Study” does not specify that this is a parallel randomized trial. Suggest revising to: “…A Parallel Randomized Trial in Youth Athletes” 

According to the suggestion, the title has been modified.

Page 1, Lines 11–26 (Abstract): I recommend inserting “registered at ClinicalTrials.gov (NCT05645562), conducted at a high-performance sports center”.

We fully understand the importance of including information about the study registration and the location where it was conducted. However, due to the strict 200-word limit for the abstract, it is not feasible to incorporate these details without compromising the clarity and focus on the study’s main findings. Instead, the requested information is already clearly stated in the methodology section, which is the standard and appropriate place for such details according to journal and scientific writing conventions (lines 117 – 118).

Statistical outcomes are presented, but confidence intervals are missing for main results, including both effect size and 95% CI in the abstract for transparency. The term “may reduce” is cautious but should be linked to statistical evidence and limitations in the conclusion of the abstract.

We agree that including confidence intervals alongside effect sizes enhances transparency and interpretability. Accordingly, we have revised the abstract to include the 95% confidence intervals for the main results.

Regarding the “may reduce” statement, we have now linked it more explicitly to the statistical evidence and acknowledged the limitations within the abstract’s conclusion, in line with your recommendation.

Page 1, Lines 29–41: The introduction is clear but could integrate epidemiological data specific to youth athletes earlier, as most prevalence data cited (L48–49) refers to mixed or elite adult populations.

According to the recommendations, we have focused on youth athletes. Specifically, we examined how fear affects youth athletes with a prior injury, and we clarified that the reported prevalence of pain comes from heterogeneous age samples. To address this, we also provided the mean ages of the study populations, which indicate that youth athletes were included (lines 38-42 and 55-57)

At L37–41, central sensitization is mentioned but not clearly linked to catastrophizing in healthy youth. This connection should be made explicit to justify the intervention in a non-injured sample.

We appreciate the reviewer’s comment regarding the link between catastrophizing and central sensitization in healthy youth. We have clarified this connection in the revised manuscript by explicitly stating that anticipatory thoughts and negative pain expectations in healthy youth athletes can alter pain processing and promote central sensitization, even in the absence of injury. This clarification can justify the relevance of investigating catastrophizing in a non-injured sample (lines 42-46).

Page 2, Lines 79–90: The section on sex differences states “to the authors’ knowledge…” - introduce a  brief search strategy or key citations to justify the novelty claim.

We thank the reviewer for this comment. We have clarified the novelty claim by including a brief search strategy in the revised manuscript. Specifically, we conducted a search of MEDLINE and Web of Science using the terms ‘catastrophizing,’ ‘youth athletes,’ and ‘sex differences,’ which did not identify any studies explicitly examining sex differences in catastrophizing among youth athletes (lines 93-96).

Page 3, Lines 99–109 (Design): Although trial registration and ethics approval are reported, the randomization process lacks detail on sequence generation and allocation concealment (e.g., method used by third person to assign groups beyond “OxMaR software”). Clarify whether stratification by sex or sport type occurred.

According to the suggestion, we have clarified the randomization process (lines 141-144).

 Page 3, Lines 110–116 (Sample size): Provide assumptions justification: effect size choice (3.5 PCS points), clinical relevance, and whether this is the minimal clinically important difference (MCID).

According to the recommendation, we have now clarified the rationale for selecting a 3.5-point difference on the Pain Catastrophizing Scale (PCS) as the target effect size. Also, it falls within the range of minimal clinically important difference (MCID) values reported for the PCS, which vary between 1.9 and 13.6 points depending on the population and methodology used. We have updated the manuscript to reflect this justification (lines 122 – 131).

Page 3–4, Lines 125–131 (Blinding): Specify how participants were masked to the intervention's aims (if at all)—important for behavioral interventions. Report whether the outcome assessors were blinded to pre/post timing in addition to group allocation.

According to the recommendation, we have clarified the blinding procedure (lines 144-151).

Page 4, Lines 149–152 (Injury registration): Describe injury classification criteria from the Oslo questionnaire (time-loss vs medical attention injuries) to ensure reproducibility.

According to the suggestion, the injury classification criteria from the Oslo questionnaire was described (lines 172-177).

Page 4, Lines 153–165 (Educational program): Provide content validation process for PNE material; was it piloted or reviewed by experts before delivery?

We have clarified in the manuscript that the educational program was reviewed for content validity by experts in sports medicine and pedagogy prior to its implementation (lines 178-179).

Page 4, Lines 166–181 (Statistical analysis): Report handling of missing data and dropouts in analysis, specifying whether intention-to-treat (ITT) or per-protocol analysis was used.

According to the suggestion, we have included in the analysis that the missing data and dropouts were performed according to the intention-to-treat (lines 206-208).

Page 5, Lines 182–184: Flow diagram is present but lacks detailed numbers for exclusions and reasons.

This information has been added to the flow diagram, as suggested (Figure 1).

Page 5, Lines 193–194 (Table 1): Check inconsistencies in height units for IG female athletes, likely typo: “172.22” instead of “1.72 m”.

Checked.

Page 5–6, Lines 197–206: Between-group non-significance is mentioned, but effect sizes and 95% CIs for these null results should be reported to aid interpretation.

Effect sizes and 95%CI have been added to Table 2.

Page 6, Lines 210–212: The finding of higher helplessness in females is important but underemphasized, suggest including it in the abstract.

We agree that this is a relevant and noteworthy result. However, due to the strict 200-word limit imposed for the abstract, it is not feasible to include this detail without omitting other key findings related to the main outcome and statistical interpretation.

To ensure clarity and focus, the abstract prioritizes the primary objective and results of the study, including overall catastrophizing changes, sex differences, and injury rates.

Instead, the finding on helplessness has been emphasized in the Discussion section, where it is appropriately contextualized and interpreted (lines 303-312).

Page 7, Lines 217–226: The opening paragraph restates results but should also quantify changes for context (e.g., “mean reduction of 2 PCS points in IG males”).

Accordingly, we have revised the opening paragraph of the Discussion section to include the mean reduction in PCS scores among IG males, which was 2.0 points (lines 250 – 252).

Page 7, Lines 240–245: The explanation for null between-group differences (“low baseline catastrophizing”) should be supported by reporting baseline mean values in this section.

According to the recommendation, we have added the catastrophizing baselines mean values in this section (line 272).

Page 8, Lines 248–260: Sex-specific cultural factors are discussed but no direct evidence from this study is presented; recommend citing qualitative or survey data if available, or acknowledging this as speculative.

We have revised the text to acknowledge that sex-specific cultural factors were not directly assessed in this study and may influence the observed differences (lines 283-287)

Page 8, Lines 262–267: Injury multifactoriality is acknowledged but could integrate a brief comment on whether monitoring of load or fatigue could be added in future designs.

We thank the reviewer for this comment. We have integrated a brief comment on whether monitoring of load or fatigue could be added in future designs (lines 300-302).

Page 9, Lines 288–297: Good coverage of limitations, but should explicitly mention lack of follow-up period to assess sustainability of effects, key for behavioral interventions. Should also state potential Hawthorne effect due to repeated questionnaire contact.

We agree with the reviewer and have added both the lack of a follow-up period to assess sustainability of effects and the potential Hawthorne effect due to repeated questionnaire contact to the limitations section of the manuscript (lines 333-337).

Page 10, Lines 321–324: Funding statement says “no external funding”, but should clarify whether in-kind support (venue, staff salaries) from the High-Performance Sport Center influenced study design or conduct.

We confirm that the study did not receive any external funding, and no in-kind support from the High-Performance Sport Center (such as staff involvement, venue sponsorship, or logistical assistance) had any influence on the study design, conduct, or analysis. All procedures were carried out independently by the research team. We have revised the funding statement to clarify this point.