Pain neuroscience education (PNE) has changed our practice as clinicians, our knowledge and the way we interact with patients. But does it change short-term or long-term pain and disability in patients with persistent low back pain? Until recently, three systematic reviews had been undertaken to evaluate the effect of PNE in persistent non-specific low back pain  or musculoskeletal conditions [2,3]. However, none of these were able to perform meta-analyses due to too few trials included  or too much heterogeneity [2,3],unable to give an overall score of effectiveness to guide us clinicians in understanding how useful PNE is in clinical practice.
In our systematic review, we evaluated the effect of PNE compared to no PNE (waiting list controls, usual care interventions, or any other treatment as long as it didn’t include PNE). We limited the PNE definition to that used by Butler & Moseley which relates to Explain Pain neuroscience , as opposed to cognitive functional therapy and anatomical or non-specific pain education. We also only included patients with non-specific persistent low back pain of at least 3 months duration. All included trials needed to be RCTs, and include pain and/or disability as outcomes. We searched the CINAHL, Medline, Web of Science and Cochrane databases for RCTs between 2011 and December 2017 and contacted authors known for their work in pain neuroscience to ensure no papers were missed (G.L Moseley, J Nijs and A Louw).
Our review included 7 randomised controlled trials that compared the addition of PNE to either no PNE, biomedical education, GP care, or usual physiotherapy. There were three education only trials [6–8], and five trials including a form of physiotherapy (dry needling , aquatic exercise , multi-modal treatment [11,12], or manual therapy ). Sample sizes ranged from 12 to 216, with an average age from 38 to 60 years. One trial was of high quality , the other seven were of moderate quality due to inadequate blinding of providers.
Our results demonstrated low quality evidence for the use of PNE in reducing short-term pain, when compared to no use of PNE. However, when we performed a sub-group analysis comparing use of PNE in addition to physiotherapy and the control group (physiotherapy only), the size of the difference was larger, and was statistically significant but not clinically significant according to Hawker et al . With regard to disability, our results demonstrated an overall clinically and statistically significant weighted mean improvement in the short term outcomes for PNE compared to control. . However, when the trials were sub-grouped according to PNE in addition to physiotherapy compared to usual physiotherapy, the weighted mean difference was even larger, and again was both statistically significant and clinically meaningful . This was supported by moderate quality evidence using the GRADE evaluation.
Only two trials followed up participants and examined the long–term effects of PNE on pain and disability, but unfortunately both studies were of very low quality [8,12]. Three trials used the Tampa scale of kinesiophobia [6,10,16] to assess psychological effects and found a statistically significant result in favour of the use of PNE in comparison to no PNE but this was clinically insignificant. Due to the small number of trials including this outcome, sub-group analysis was not possible.
So what does this review tell us? Moderate evidence was found for the use of PNE in improving disability in the short-term, irrespective of whether it is delivered in conjunction with physiotherapy or not. There is also moderate evidence that PNE added to usual physiotherapy slightly improves pain scores in the short-term. The trials included appeared to have a low level of bias, however, the most common source of bias was lack of blinding of outcome assessors. The small sample sizes of some of the included trials reduced the ability of the trial to detect a significant difference, as well as reducing the likelihood that significant results represent a true effect . There was a wide variety in the delivery characteristics of PNE across the included trials;one trial delivered a PNE explanation for a manual therapy technique lasting on average 5 minutes , whereas the other trials included 2-3 hours of PNE in various formats (webinars, individual, group). The short-term follow-up varied across the trials from same-day  to 3 months after baseline (with a mean of 33.7 days).
A large multi-centre trial would be useful to validate these results across different populations, with different intervention deliverers. The evidence base is growing, however to date, we can conclude that there is added benefit of combining PNE with usual therapeutic interventions to reduce short-term disability and pain outcomes, but this evidence is lacking for long-term outcomes.
About Lianne Wood
Lianne is a clinical academic physiotherapist who is currently undertaking her PhD at the Research Institute for Primary Care and Health Sciences, Keele University. She is investigating whether matching the primary outcome of exercise RCTs in persistent low back pain to the treatment aims of the exercise intervention changes the conclusions of the RCTs. She is also exploring what the treatment aims of exercise interventions are in persistent low back pain. She continues to work clinically as a physiotherapist and spinal advanced practitioner in Nottingham.
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