Effect of Pain Neuroscience Education Combined With Cognition-Targeted Motor Control Training on Chronic Spinal Pain

Abstract

IMPORTANCEEffective treatments for chronic spinal pain are essential to reduce the related high personal and socioeconomic costs.OBJECTIVE To compare pain neuroscience education combined with cognition-targeted motor control training with current best-evidence physiotherapy for reducing pain and improving functionality, gray matter morphologic features, and pain cognitions in individuals with chronic spinal pain. DESIGN, SETTING, AND PARTICIPANTSMulticenter randomized clinical trial conducted from January 1, 2014, to January 30, 2017, among 120 patients with chronic nonspecific spinal pain in 2 outpatient hospitals with follow-up at 3, 6, and 12 months. INTERVENTIONS Participants were randomized into an experimental group (combined pain neuroscience education and cognition-targeted motor control training) and a control group (combining education on back and neck pain and general exercise therapy). MAIN OUTCOMES AND MEASURES Primary outcomes were pain (pressure pain thresholds, numeric rating scale, and central sensitization inventory) and function (pain disability index and mental health and physical health). RESULTS There were 22 men and 38 women in the experimental group (mean [SD] age, 39.9 [12.0] years) and 25 men and 35 women in the control group (mean [SD] age, 40.5 [12.9] years). Participants in the experimental group experienced reduced pain (small to medium effect sizes): higher pressure pain thresholds at primary test site at 3 months (estimated marginal [EM] mean, 0.971; 95% CI, -0.028 to 1.970) and reduced central sensitization inventory scores at 6 months (EM mean, -5.684; 95% CI, -10.589 to -0.780) and 12 months (EM mean, -6.053; 95% CI, -10.781 to -1.324). They also experienced improved function (small to medium effect sizes): significant and clinically relevant reduction of disability at 3 months (EM mean, -5.113; 95% CI, -9.994 to -0.232), 6 months (EM mean, -6.351; 95% CI, -11.153 to -1.550), and 12 months (EM mean, -5.779; 95% CI, -10.340 to -1.217); better mental health at 6 months (EM mean, 36.496; 95% CI, 7.998-64.995); and better physical health at 3 months (EM mean, 39.263; 95% CI, 9.644-66.882), 6 months (EM mean, 53.007; 95% CI, 23.805-82.209), and 12 months (EM mean, 32.208; 95% CI, 2.402-62.014). CONCLUSIONS AND RELEVANCEPain neuroscience education combined with cognition-targeted motor control training appears to be more effective than current best-evidence physiotherapy for improving pain, symptoms of central sensitization, disability, mental and physical functioning, and pain cognitions in individuals with chronic spinal pain. Significant clinical improvements without detectable changes in brain gray matter morphologic features calls into question the relevance of brain gray matter alterations in this population.TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02098005

Pain Neuroscience Education and Physical Therapeutic Exercise for Patients with Chronic Spinal Pain in Spanish Physiotherapy Primary Care: A Pragmatic Randomized Controlled Trial

“…Similar results in terms of the physical summary component were achieved in an intervention based in education and a multimodal physical therapy program with deep-water running, although in that study, outcomes were measured at 15 weeks and patients were younger than those in our study [64]. Another recent study found moderate effect size after the application of PNE combined with cognition-targeted motor control training in patients with CSP [62]. We consider that an intervention with an extensive PNE program and PE with playful components is responsible for this improvement in post-intervention quality of life that is maintained at 6 months.…”

“…Thus, a therapeutic approach based on the combination of PNE and PE can improve quality of life and disability, decreasing the pain intensity of patients with CMP and those suffering from chronic spinal pain (CSP). Different clinical trials and reviews have shown promising results combining PNE and PE [45,46,48,[62][63][64][65][66], but there is no consensus on the optimal dose of PNE or PE. These types of interventions, in which the patient is the active part of the treatment, are not performed and have been scarcely evaluated in primary care (PC).…”

Lifestyle and Chronic Pain across the Lifespan: An Inconvenient Truth?

“…A recent randomized controlled trial examined the effectiveness of pain neuroscience education combined with cognition‐targeted exercise therapy, versus current best‐evidence rehabilitation for improving pain, dysfunction, and brain characteristics in people with chronic spinal pain . Pain neuroscience education plus cognition‐targeted exercise therapy was superior to current best evidence rehabilitation to reduce pain and symptoms of central sensitization and to improve psychophysiological measures of central sensitization, disability, pain cognitions, mental health, and physical functioning (medium to large effect sizes) . Still, neither this new conservative approach to chronic pain nor current treatments for chronic pain address important lifestyle factors such as sleep, stress, or diet.…”

“…Therefore, they should be addressed prior to initiating the behavioral lifestyle intervention. For instance, pain neuroscience education can decrease catastrophic thinking and fear of movement, allowing people to increase physical activity levels and engage in exercise interventions …”

Central sensitisation: another label or useful diagnosis?

“…When treatment for chronic pain takes CS into account, it can substantially improve symptoms and psychophysiological testing reflecting CS alongside the clinical improvement (in terms of pain severity and functional improvement—medium to large effect sizes) 53. Cardinal to taking CS into account, is not relying on short-term changes in pain (severity).…”