Pain Neuroscience Education (PNE) is Relatively Ineffective: Research Confirmed

Review and Commentary on the Comparative Studies Investigating Pain Neuroscience Education

by Brent Brookbush DPT, PT, MS, CPT, HMS, IMT

Pain Science Has a Problem

Pain science research currently has an interesting problem. It is amazing work, by incredible professionals, that has helped to inform theoretical frameworks on physical rehabilitation. However, the relatively strong correlations made between pain and psychosocial factors (demonstrated in some research studies), have resulted in a focus on addressing these psychosocial factors with cognitive interventions. The problem is these cognitive approaches do not have a large effect on the factors they are attempting to address, and worse, changes in cognitive factors seem to have little if any effect on objective outcome measures (e.g. pain-free range of motion, neck disability index scores, etc.). At the very least, these cognitive approaches are far less effective than manual therapy, specific exercise, and other effective modalities. Author's note, it seems that a surge in the amount of research published on pain science was highjacked by a relatively ineffective application of that research (e.g. pain science education (PNE)). Worse still, some individuals have asserted that this surge in research and popularity of PNE programs is evidence of PNE being "new and better" while discrediting other more effective modalities. This type of strategy has won political campaigns, but it is not evidence-based practice.

Thought Experiment on "Best Possible Treatment"

Imagine placing every possible physical rehabilitation technique in a pile on a table, regardless of our professional titles or personal preferences. Which techniques would we select from this pile for our patients? I am assuming most of us would select the best possible techniques or the best possible combination of techniques. To keep it relatively simple and objective, we could base the definition of "best possible" on two objective measures: reliability (the percentage of time it results in a positive outcome) and effect size (the amount of improvement made). The number of techniques we could select would be limited by the length of a session; that is, we could only select the number of techniques that we could comfortably perform within the length of a normal session. Based on these standards, pain neuroscience education (PNE) would likely rarely if ever be chosen in an outpatient orthopedic physical rehabilitation and/or sports medicine clinic (e.g. issues including chronic low back pain, shoulder impingement syndrome, acute ACL ruptures, etc.). Based on the research below, PNE may be the ice and TENS of the next generation of therapists. Occasionally, these modalities are beneficial to improve a patient's compliance or ability to initially endure an intervention plan, but they cannot be considered the basis of a therapeutic approach, should comprise an exceedingly small portion of therapy time, and billing for these modalities should be minimal.

• Fact: The factors that correlate most with the experience of pain, are not as important as the magnitude of change that can be made for any correlated factor, and the effect that change has on patient outcomes.

Caption: Physical Therapist treating a patient with thoracic pain. Is Pain Neuroscience Education (PNE) the best approach?

Included in this review: This review includes all of the research that could be located comparing pain neuroscience education (PNE) to other interventions for conditions commonly addressed in an outpatient orthopedic or sports medicine clinic. This review does not include research investigating the treatment of complex chronic pain conditions (e.g. complex regional pain syndrome (CRPS)). Further, since the goal of this article was to determine the relative efficacy of PNE, studies that lacked a direct comparison to another intervention were not included. Some research suggests that PNE may have a positive effect on certain outcome measures when compared to controls; however, our goal was to determine whether this intervention exhibited a superior benefit for patients, and should be prioritized over other effective interventions. There is always a limit on session time, and the time a client or patient is willing to commit to therapy.

Research Summary Statement:

The randomized controlled trials (RCTs) available that compare pain neuroscience education (PNE) to other interventions imply that PNE is unlikely to be more effective than biomedical education, and is unlikely to result in additional benefit when added to supervised manual therapy, exercise, and/or the combination of other effective interventions. Further, the addition of manual therapy and exercise to PNE reliably results in significant improvement in patient outcomes, implying that PNE alone cannot be considered an optimal treatment approach. The addition of PNE to a home exercise program may enhance patient outcomes (perhaps due to enhanced effort and compliance during exercise). Last, PNE does reliably improve Tampa Scale of Kinesiophobia (TSK) scores; however, the validity of this finding and/or correlation with other recovery outcome measures is questionable.

• Of the 10 studies in this review comparing similar intervention plans with and without PNE, 4 studies demonstrate no difference, 3 studies only demonstrate a significant difference in TSK scores, and 3 studies exhibit significant improvements in 1 additional outcome measure. Unfortunately, the additional outcome measures are likely statistical variance. These additional outcome measures are either easily influenced by subjective or cognitive factors (FABQ and Pain), represent a difference in one outcome with other similar outcomes not demonstrating difference, and/or the difference was only demonstrated during one of the multiple time points. In short, the gross majority of comparative research demonstrates that PNE is not reliably effective for improving objective patient outcome measures.

"Teaching to the Test" and the problem with the Tampa Scale of Kinesiophobia (TSK)

Teaching someone pain neuroscience education, and then testing them on their knowledge and beliefs on pain science-related topics (e.g. Tampa Scale of Kinesiophobia (TSK)) cannot be considered an objective measure of improvement for orthopedic dysfunction. The first issue is the creation of a tautological argument. A tautological argument is otherwise known as "circular logic," and is defined as an argument that starts with the assumption that is meant to be proven by the argument itself. For example, "I can decrease pain catastrophizing by teaching about pain catastrophizing." An easier way to look at this logical issue is the idea of "teaching to the test", and creating a "test that is easier to teach to." Although tautological logic can aid in honing an intervention to an assessment and vice versa, it does not permit consideration of whether the assessment and intervention are valid. For example, "Does pain catastrophizing have a significant effect on objective outcome measures of recovery from low back injury or chronic pain?" Although "pain catastrophizing" is bad, a pain-free range of motion measured with goniometry is a more valid objective measure of recovery. When considering pain science education, research most often demonstrates that PNE is only consistently more effective for improving TSK scores, which is a test of the patient's beliefs and knowledge of pain science-related topics. These same studies most often demonstrate no difference in reliable objective outcome measures based on motion or function. In short, if you removed the TSK from the studies below, there would be almost no support for PNE. Note, that this also may suggest that the TSK is not a valid outcome measure for recovery from orthopedic pain and injury.

• An analogy: The issues with PNE and the TSK are similar to teaching a patient who has contracted a deadly virus about anti-viral drug risks, then giving them a quiz on the risks and fear associated with taking anti-viral drugs, and then considering improvements on the quiz a positive indicator of virus recovery. Reducing fear is a positive outcome for a patient's mental health, and a reduction in fear may help someone resume healthy behaviors that can promote better recovery. However, these are not strong indicators of recovery when compared to the absence of the virus in a blood or saliva test. Therefore, education cannot be considered an ideal treatment option when effective anti-virals are available. Similarly, there are better objective measures of recovery for orthopedic pain than the TSK, and research comparing PNE demonstrates this intervention is far less effective than manual therapy, exercise, and other interventions on more valid objective outcome measures.

Caption: Individual experiencing lower leg pain. Is this the result of tissue injury or could it be psychosamatic (e.g. treatable with cognitive appraches to pain).

A Patient Testimonial: Pain Science Taken Too Far

Some in the pain science community have misinterpreted the research to assert an extreme conclusion that "pain is in your head", and/or "pain is an imagined construct not dependent on tissue insult." Many professionals have used this extreme position to assert that physical rehabilitation should no longer focus on the assessment and treatment of movement impairments. Although this may not have been the original intent of the leaders in pain science education and research, they have done little to oppose the movement. The testimonial below is an example of how patients are affected by this extreme conclusion and the complicity of pain science educators and researchers.

An unprovoked testimonial that was left on a BrookbushInstitute.com Facebook post:

“I have had chronic lower back pain since I was 18 years old (now 54 years old). About 10 years ago, at the same time I had my prostate removed, the local hospital’s pain management team introduced me to the idea of "perceived" or " learned pain". They gave me heaps of advice and strategies on how to "outthink the pain,” which at that point (my pain) was exacerbated by movement of any kind.I felt insulted by their attitude, which implied I did not understand the "new science of pain management.” Despite trying their recommended strategies, which included some CBT (cognitive behavioral therapy), I soon resorted to my regular physical therapy and pain meds, sadly. But that's only me. The height of my disgust was a new graduate Physiotherapist telling me that I was "imagining" my pain” – Russell Isaacs

• This quote has been copy-edited; the original comment is the screenshot below.

It is hard to imagine the audacity of a young new grad looking a grown adult in the face and telling him that his suffering is imagined. This is blaming the patient’s issues on the patient, and implying they could have just "thought differently" and 30+ years of suffering would never have occurred. It is hard to imagine the quality of life issues, the sacrifices, the missed opportunities, the financial cost of therapy on and off for 30 years, and the times they lost their temper with their wife, kid, or dog, because of the mental fragility that comes with unrelenting pain. And then, they show up to physiotherapy and some new grad tells them, "It's all in your head." This is obviously not ideal pain science education, but this is the effect those educating on pain science have had on the profession. If the leaders in pain science education and research expect to have a positive impact on our field, they must take responsibility for both the intent AND THE EFFECT of their messaging.

Caption: Ori

A Better Solution (Including Pain Science Education)

1. Demonstrate empathy ("We will find a solution").
2. Implement an evidence-based, integrated, systematic, client-centered, and outcome-driven approach.
   • Generally, research supports a combination of manual therapy , specific exercises , and some modalities , based on reliable objective movement assessments , with the intent of reducing movement impairments .
3. Increase autonomy by developing a self-management plan (e.g. home exercise plan).
4. Educate the patient when they are interested or when it may be beneficial for compliance, and education should occur during the implementation of other physical interventions.

An example of better communication based on pain science research.

• “Stressors in life can amplify pain, so if you happen to notice an unprovoked increase in your symptoms, don’t panic, and take a second to assess your stress, anxiety, mood, etc. If they are abnormal, take a bit of solace in knowing that this could be amplifying your symptoms. It is likely that the issue that brought you to my office, did not get worse, and your symptoms will go back to the level of intensity they were at when your mental state returns to baseline. Sometimes, just knowing this bit of information will give you some relief. Now… let’s get to work finding interventions that will help address the original issue, and let’s work on building a home exercise program that you can use to address the issue yourself.”

Caption: Is neck pain biomechanical, psychosomatic, or both?

Research Review Summary:

• Pain Neuroscience Education (PNE) versus Biomedical Education: Research suggests that patient education may not affect patient outcomes, that there is no significant difference between conventional biomedical education and PNE on patient outcomes (e.g. pain, function, or fear avoidance), and/or that if PNE has a significant effect, it is only related to specific subsets of questionnaires like the Tampa Scale of Kinesiophobia.
• Exercise with and without Pain Neuroscience Education (PNE): Research demonstrates conflicting results regarding the effectiveness of PNE when added to exercise. Matias et al. (2019) demonstrated that adding PNE to exercise had no effect on outcomes, and Pardo et al. (2018) demonstrated that PNE improved subjective pain intensity, lumbar pain pressure threshold, finger-to-floor distance test, and pain catastrophizing, but not the Oswestry Disability Index (ODI) or Pain Catastrophizing Scale (PCI) scores. Assuming that the Matias et al. (2019) exercise program was supervised (details were missing from the study), it may be hypothesized that PNE has a positive effect on compliance and effort during a home exercise program, but less influence when exercise sessions are supervised.
• Manual Therapy and Exercise with and without Pain Neuroscience Education (PNE): Research that PNE is as effective as a minimally invasive stretching program, and/or equally as effective as exercise when added to manual therapy. However, the addition of PNE to manual therapy and exercise is likely to only improve Tampa Scale of Kinesiophobia (TSK) scores.
• Additional Interventions with and without Pain Neuroscience Education (PNE): The addition of PNE is unlikely to result in additional improvement in a variety of outcome measures for pain, function, capacity, fear avoidance, anxiety/stress, and health when added to interdisciplinary multimodal pain therapy, dry needling, or aquatic therapy. Again, a possible exception is the effect of PNE on the Tampa Scale of Kinesiophobia scores. Note, that 1 study demonstrated that the addition of PNE resulted in significantly larger improvements in subjective pain, and another study demonstrated larger improvements in pain pressure threshold; however, because of the subjective nature of these tests, the differences occurred in separate studies, and difference happening during only 1 of the multiple time-points assessed, these data points are unlikely to be more than a statistical variance.
• Comparing Intervention Plans that include Pain Neuroscience Education: Research implies a combination of PNE and specific physical interventions may be superior to some combinations of manual therapy/modalities and exercise; however, the design of the studies in this section prevented determining correlations between outcomes and any single intervention. Author note, if the other studies in this review demonstrated that PNE resulted in reliably superior outcomes, then it may have been reasonable to assume that PNE had a significant effect on the outcomes in these studies. However, since the majority of the research demonstrates that PNE is not reliably effective, it is likely more reasonable to assume that the other interventions had a larger influence on outcomes.
• Pain Neuroscience Education (PNE) with and without Exercise: Research demonstrates that adding exercise to PNE significantly improves physical function, disability, health-related quality of life, global perceived effect, and pain intensity.
• Pain Neuroscience Education (PNE) with Exercise and Manual Therapy: In summary, these studies demonstrate that the addition of exercise and/or manual therapy to patient education and advice may result in significantly larger improvements in pain, function, disability, quality-of-life, and/or range of motion.

Research Review

No Difference Between Pain Neuroscience Education (PNE) and Biomedical Education

Several studies have compared PNE to more conventional biomedical education. An RCT by Derebery et al. compared 187 patients (age: 20 – 60 years) with first-time neck pain. Patients were randomly assigned to receive “The Neck Book” (pain science education), the "Neck Owner's Manual" (traditional education), or no educational material. Outcome measures included the Fear Avoidance Beliefs Questionaire (FABQ), and the Neck Pain and Disability Scale at 2-weeks, 3-months, and 6-months. The findings demonstrated no significant differences between the 3 groups on any of the outcome measures during any follow-up periods. For example, at 6-months, the experimental booklet, traditional booklet, and no-booklet groups reported The Neck Pain and Disability Scale mean scores (SDs) of 31.3 (15.5), 35.3 (17.0), and 31.8 (15.6), respectively. Similarly, there were no significant effects for FABQ scores: 35.9 (21.5), 40.3 (22.1), and 38.0 (23.4), respectively) (1). Lluch et al. compared 44 hospital patients with knee osteoarthritis pain for more than 3 months, scheduled for total knee replacement surgery, with no history of lower limb surgery within 6 months of the study, and no history of inflammatory disease, metabolic disease, neurological disease, fibromyalgia, or cognitive impairments. All patients received “pain guided” knee joint mobilizations (Mulligan techniques), and were randomly assigned to groups receiving pain neuromuscular education (PNE) (age: 72.8 ± 5.6 years), or biomedical education (age: 67.7 ± 7.8 years). All participants performed manual Mulligan mobilizations, for 4 weeks, 1 supervised session/week, 3 sets/session, and 10 reps/set, and were instructed to perform self-administered mobilizations for 4 weeks, 1x/day, 4 sets/day, 20 reps/set. The PNE group received a pain education booklet, and the biomedical education group received information on the anatomy and biomechanics of the knee, etiology, symptoms, treatments, and surgical intervention with no mention of underlying pain mechanisms. Outcome measures included pain pressure threshold, temporal summation, conditioned pain modulation, widespread hyperalgesia, the central sensitization inventory (CSI), pain catastrophizing, and the Tampa Scale for Kinesiophobia (TSK), assessed immediately after the intervention, 1-month post-intervention, and 3 months after the intervention. The findings demonstrated that neither group exhibited significant changes in temporal summation, conditioned pain modulation, widespread hyperalgesia, or the central sensitization inventory; however, the PNE group exhibited larger improvements for measures of pain catastrophizing and the Tampa Scale for Kinesiophobia (TCS) scores (psychosocial variables related to pain) (2). Last, An RCT by Adenis et al., compared 88 males and females (age: 18 – 65 years) with low back pain for more than 1 year, with an 8 or more on the Roland-Morris Disability Questionnaire, a 4 or more on the Start Back scale, with no history of serious disease, inflammatory rheumatic disease, radiculopathy, scoliosis of 30 degrees or more, 8 or more on a pain intensity scale, lumbar surgery, or pregnancy. All participants received 1 week of a multidisciplinary rehabilitation program (evaluation sessions, physical therapy, aquatic exercise, and physical activity) and were randomly assigned to groups receiving pain neuroscience education (PNE) or spine pathology and ergonomics education (SPEE). The PNE group received information provisions, metaphors, and stories designed to correct erroneous anatomic and biomechanical beliefs about pain for 1 week, 8 sessions/week, 30 minutes/session (5 hours total). The SPEE group received a manual therapy program (focused on loosening stiff structures, muscle reconditioning, and better load distribution and the adoption of correct movements and postures) and received information on functional anatomy of the spine and ergonomics of daily activities and sports activities to reassure patients about the benign nature of low back pain and to attribute the persistence of pain to an overall muscle and/or joint dysfunction related to poor posture, stiffness, and a lack of activity for 1 week, 8 sessions/week, 30 mins/session (5 hours total).
The findings demonstrated that neither group exhibited significant changes in Roland-Morris Disability Questionnaire scores, Dallas Pain Questionnaire scores (daily activity, work, and leisure, anxiety and depression subscales), Fear Avoidance and Belief Questionnaire scores (physical activity and work subscales), pain catastrophizing scores, Tampa Scale of Kinesiophobia scores, and Hospital Anxiety and Depressions Scale scores (anxiety) immediately, 5 days, or 90 days after the intervention. Note that the PNE group did exhibit a significant improvement in 3 subsets of scores, including the Social Interest Subscale on the Dallas Pain Questionnaire, Depression Scale Scores on the Fear Avoidance and Belief Questionnaire, and Hospital Anxiety Depressions Scale (21). These studies suggest that patient education may not affect patient outcomes, that there is no significant difference between conventional biomedical education and PNE on patient outcomes (e.g. pain, function, or fear avoidance), and/or that if PNE has a significant effect, it is only related to specific subsets of questionnaires like the Tampa Scale of Kinesiophobia.

Exercise with and without Pain Neuroscience Education (PNE)

Two studies compared the efficacy of exercise with and without PNE. Matias et al. compared university students with chronic neck pain. Participants were randomly assigned to an exercise-only group (e.g. neck flexor, neck extensor, and scapular stabilizer endurance exercise), or an exercise and PNE group. Outcome measures included pain intensity, disability, fear of movement, catastrophizing, knowledge of pain, pain pressure thresholds, neck and scapular muscle endurance, and knowledge of pain neurophysiology immediately and 3 months post-intervention The findings demonstrated both groups exhibited a significant and similar improvement for all outcome measures, except for a larger improvement in knowledge of pain neurophysiology exhibited by the PNE group (3). A single-blind RCT by Pardo et al. compared 65 patients (age: 20 – 75 years) with nonspecific chronic low back pain for 6 months or longer, and no history of lumbar radiculopathy, osteoporosis, arthritis, fractures, tumor, infection, metastasis, or participating in other treatment at the time of the study. Participants were randomly assigned to an exercise group (aerobic exercise, motor control for the lumbar spine, and stretching) or an exercise and PNE group. Both groups received 2 supervised sessions, 30 days apart. The first session instructed the patients on the exercises to be performed at home daily, and the second session reviewed the home exercise program (compliance was assessed during the second session with a Likert scale during the follow-up assessment). The PNE group received an additional 30-50 minutes of counseling during each session. Outcome measures included lumbar pain pressure threshold, finger-to-floor distance, Oswestry Disability Index (ODI), Pain Catastrophizing Scale (PCI), Global impression of change score, and subjective pain intensity, immediately, 1 month, and 3 months after the intervention. The findings demonstrated that the exercise and PNE group exhibited significantly larger improvements in subjective pain intensity, lumbar pain pressure threshold, finger-to-floor distance test, and pain catastrophizing during the 3-month follow-up when compared to the exercise-only group (4). These studies demonstrate conflicting results regarding the effectiveness of PNE when added to exercise. Matias et al. (2019) demonstrated that adding PNE to exercise had no effect on outcomes, and Pardo et al. (2018) demonstrated that PNE improved subjective pain intensity, lumbar pain pressure threshold, finger-to-floor distance test, and pain catastrophizing, but not the Oswestry Disability Index (ODI) or Pain Catastrophizing Scale (PCI) scores. Assuming that the Matias et al. (2019) exercise program was supervised (details were missing from the study), it may be hypothesized that PNE has a positive effect on compliance and effort during a home exercise program, but less influence when exercise sessions are supervised.

Manual Therapy and Exercise with and without Pain Neuroscience Education (PNE)

Several studies compare combinations of exercise, manual therapy, and PNE, demonstrating significant differences in efficacy. An RCT by Poulsen et al., compared 111 patients with clinical and radiographic confirmed unilateral hip osteoarthritis, randomly assigned into a pain education group, pain education plus manual therapy group, or minimal control intervention group (home stretching). Outcome measures included self-reported short-term (6 weeks) and long-term (1 year) pain severity on an 11-point numeric rating scale (NRS) post-intervention. The findings demonstrated the pain education plus manual therapy group exhibited greater improvements in both short-term and long-term pain scores (NRS) compared to the pain intervention group and minimal control intervention group. Further, there was no significant difference between the pain education group and the minimal intervention group (5). An RCT by Saracoglu et al. compared 69 hospital patients (age: 18 – 65 years) with chronic low back pain for at least 6 months, and subjective pain intensity of 5/10 or more, with no history of spondylolisthesis, lumbar stenosis, spondyloarthropathy, osteoporosis, spine or lower extremity surgery, or systemic inflammatory disease. Participants were randomly assigned to a home exercise-only group, a home exercise and manual therapy group, and a home exercise, manual therapy, and PNE group for 4 weeks. All participants performed a home exercise program including exercises for the abdominals, erector spinae, gluteal muscles, quadriceps, and hamstrings, 3x/day, 10 reps/exercise. The manual therapy group received low velocity, mid-range anterior-to-posterior, unilateral joint mobilizations, and mobilizations with movement for the lumbar spine, 2x/week, 30 mins/session. The PNE group received an education presentation on metaphors, anecdotes, and pictures in a slide presentation prior to the manual therapy session 1x/week, 40-45 mins/session. Outcome measures included subjective pain intensity, Back Performance Scale, Oswestry Disability Index (ODI), and Tampa Scale for Kinesiophobia (TCS) assessed immediately and 12 weeks after intervention. The findings demonstrated that all 3 groups exhibited significant and similar improvements in back pain performance scale scores. The 2 groups including manual therapy exhibited significantly larger improvements in subjective pain intensity and ODI scores. And, the group including PNE only exhibited superior improvements on the Tampa Scale of Kinesiophobia (6). An RCT by Beltran-Alacreu et al. compared 45 university staff, students, and relatives (age: 18 – 65 years) with nonspecific chronic neck pain for at least 12 weeks, and no history of whiplash, radiculopathy, herniation, neck fracture, neck surgery, arthritis, osteoporosis, tumor, metabolic disease, fibromyalgia, or vertigo. Participants were randomly assigned to a manual therapy group (control), manual therapy, and therapeutic patient education group, and manual therapy, patient education, and exercise group. Manual therapy included passive cervical facet joint movements, mobilization of the cervical spine, and high-velocity thrusts of the thoracic spine (thoracic manipulation). Therapeutic patient education included counseling about cognitive, operant, and respondent beliefs regarding pain and disability, and promoted graded activity strategies. Exercises included stabilization exercises for the deep neck flexors and extensors and self-administered mobilization techniques. All groups received 2 sessions/week for 4 weeks, with 48 – 72 hours recovery between sessions. Outcome measures included Neck Disability Index (NDI) Scores, Tampa Scale of Kinesiophobia (TSK), Fear Avoidance Beliefs Questionnaire (FABQ), neck flexor muscle endurance test, and fatigue intensity, with reassessment at 4, 8, and 16 weeks. The findings demonstrated all groups exhibited significant improvements in all outcomes during reassessment at 4, 8, and 16 weeks. The addition of therapeutic education and/or exercise improved Neck Disability Index Scores at 4, 8, and 16 weeks and neck flexor muscle endurance test scores at 8 and 16 weeks. The groups including therapeutic education exhibited larger improvements in Fear Avoidance Beliefs Questionnaire scores, but only at 4 weeks (7). These studies imply that PNE is as effective as a minimally invasive stretching program, and/or equally as effective as exercise when added to manual therapy. However, the addition of PNE to manual therapy and exercise is likely to only improve Tampa Scale of Kinesiophobia (TSK) scores.

Additional Interventions with and without Pain Neuroscience Education (PNE)

Several studies have investigated the addition of PNE to alternative therapeutic interventions. A non-randomized, controlled trial by Richter et al. compared 179 patients (age: 20 – 60 years) diagnosed with chronic back pain for longer than 6 months and no history of serious spinal pathology. All participants received interdisciplinary multimodal pain therapy for 1 hour/session, 1 session/week, for 4 weeks, additionally, 102 of the participants received an additional 1 hour session/week of PNE. Outcome measures included the Hannover functional capacity questionnaire (FFbH-R), Neurophysiology of Pain Questionnaire (NPQ-D), Fear Avoidance Beliefs Questionnaire (FABQ), 12-item Short-Form Health-Survey (SF12), Depression, Anxiety and Stress Scale (DASS-21). The findings demonstrated that both groups exhibited significant but statistically similar improvements for all outcome measures (8). An RCT by Tellez-Garcia et al. compared 12 patients (age: 18 - 65 years) with non-specific low back pain for at least 3 months, with no history of lumbar stenosis, lumbar spondylolisthesis, spinal surgery, radiculopathy, signs of nerve root compression, a positive straight leg-raise test < 45°, diminished lower extremity force or reflexes, fibromyalgia syndrome, low back pain from underlying pathology (tumor, infection, herniation, prolapsed disc, etc.), fear of needles, corticosteroid or oral medication use over the last 6 months. Participants were randomly assigned to a dry needling group (gluteus medius and quadratus lumborum trigger points) or a dry needling and neuroscience education group (30 mins/week). All participants received 3 sessions/week for 3 weeks. Outcome measures included a numerical subjective pain scale, pain pressure threshold, Oswestry Low Back Pain Disability Index (ODI), Roland-Morris Disability Questionnaire (RMDQ), and the Tampa Scale of Kinesiophobia (TSK). The findings demonstrated that the dry needling and education group exhibited significantly larger improvements in Tampa Scale of Kinesiophobia scores and pain pressure sensitivity; however, both groups exhibited similar improvements in pain, Oswestry Low Back Pain Disability Index scores, or Roland-Morris Disability Questionnaire scores (9). An RCT by Pires et al. compared 62 patients (age: 18 – 65 years) diagnosed with chronic low back pain, symptoms for 3 months or more, with no history of radiculopathy, cauda equine syndrome, history of back surgery, fracture, osteoporosis, structural deformity, infection, tumors, inflammatory disorders, current pregnancy, cardiac conditions, or respiratory conditions impeding exercise. Participants were randomly assigned to an aquatic exercise program or an aquatic exercise and pain neurophysiology education (PNE) group. Aquatic exercise included a low back aquatic exercise program for 6 weeks, 2x/week, 30-50 min/session. PNE included 2 sessions of PNE for 90 min (Butler and Moseley) addressing acute pain, transitioning from acute to chronic pain, central sensitization, the role of the brain, psychosocial factors related to pain, cognitive and behavioral responses to pain, flare-up management, and pacing. Outcome measures included subjective pain intensity, Owestry Functional Disability scores, and Tampa Scale for Kinesiophobia scores immediately following the intervention, and during a 3-month follow-up. The findings demonstrated that both groups exhibited significant and similar improvements in Oswestry Functional Disability Scores and Tampa Scale for Kinesiophobia scores immediately following the intervention and during the 3-month follow-up. Further, improvements in subjective pain intensity were similar for both groups immediately following the intervention; however, the PNE group exhibited a significantly larger improvement during the 3-month follow-up (10). In summary, these studies suggest the addition of PNE is unlikely to result in additional improvement in a variety of outcome measures for pain, function, capacity, fear avoidance, anxiety/stress, and health when added to interdisciplinary multimodal pain therapy, dry needling, or aquatic therapy. Again, a possible exception is the effect of PNE on the Tampa Scale of Kinesiophobia scores. Note, that 1 study demonstrated that the addition of PNE resulted in significantly larger improvements in subjective pain, and another study demonstrated larger improvements in pain pressure threshold; however, because of the subjective nature of these tests, the differences occurred in separate studies, and difference happening during only 1 of the multiple time-points assessed, these data points are unlikely to be more than a statistical variance.

Comparing Intervention Plans that Include Pain Neuroscience Education

Several studies suggest that PNE may be better when combined with other interventions, but the methodology of these studies makes it difficult to develop clear conclusions. An RCT by Miller et al. compared 80 adults with chronic pain and multiple comorbidities, without a history of cancer. Participants were randomly assigned to a pain science education and exercise group or a usual care group. Unfortunately, the details of pain science education, exercise, and usual care were not reported in this study. The findings demonstrated the pain science plus exercise group exhibited greater improvements in Short Musculoskeletal Function Assessment-Dysfunction and Bother Index scores, numeric pain, pain-related fear, satisfaction, and global rates of change; however, there were no significant differences between groups for pain interference, work status, fatigue, or health care visits. Author's note: This publication lacked any details regarding the interventions making it difficult, if not impossible to develop conclusions about the interventions compared (11). An RCT by Malfliet et al. compared 120 patients (age: 18 – 65 years) with chronic nonspecific spine pain for 3 months or more, and no history of neuropathy, neck or back surgery, osteoporosis, fractures, rheumatological disease, fibromyalgia, or chronic fatigue syndrome. Participants were randomly assigned to groups performing pain neuroscience education (PNE) with cognition-targeted motor control training, or conventional patient education and physical therapy. PNE with cognition-targeted motor control training included patient education on pain and performed sensorimotor control training. Physical therapy included traditional back and neck education and general strengthening (e.g. stretching, endurance exercise, and general fitness exercises). Both groups received 3 educational sessions (group session, home-based online module, and individual session) and 15 1-on-1 exercise sessions. Outcome measures included pain pressure threshold, Central Sensitization Inventory (CSI), Tampa Scale of Kinesiophobia (TSK), and 36-Item Short Form Health Survey (SF36) with reassessment at 3, 6, and 12-month follow-up. The findings demonstrated that the PNE and motor control training group exhibited significantly larger improvements in pain pressure threshold, CSI, TSK, and SF36 scores. As noted in each of the following studies, the inclusion of different physical interventions makes it impossible to determine the true effect of patient education in this study (12). An RCT by Galan-Martin et al. compared 156 participants (age: 18 – 70 years) with spine pain, and no history of surgical intervention of the spine, cauda equina syndrome, myopathies, neurological disorders, fibromyalgia, regional pain syndrome, chronic fatigue syndrome, cancer pain, cognitive impairment, or treatment with alternative therapy. Participants were randomly assigned to 2 groups. The PNE group received PNE for 6 sessions (10 hours) and group physical exercise with playful, dual-tasking, and socialization-promoting components for 6 weeks, 3x/week (18 sessions/hour total). The conventional physical therapy group received thermotherapy, analgesic electrotherapy, and therapeutic exercises for 15 sessions. Outcome measures included health-related quality of life (HRQL), pain catastrophizing scale (PCS), Tampa Scale for Kinesiophobia scores, central sensitization inventory (CSI), Roland–Morris disability questionnaire, Oswestry Low Back Disability Index, pain intensity, pain pressure threshold, and analgesic consumption at initial assessment, immediately post-intervention, and 6-months post-intervention. The findings demonstrated that the PNE group exhibited larger improvements immediately and 6 months post-intervention for pain HQRL, PCS, Tampa Scale for Kinesiophobia scores, Oswestry Low Back Disability Index scores, pain intensity, and pain pressure threshold and lower analgesic consumption 6 months post-intervention. Again, this study compared two very different intervention plans, based on different models and assessment criteria (13). An RCT by Vibe et al. compared 121 participants (age: 18 – 65 years) with nonspecific chronic low back pain and no history of radicular pain, disc herniation, spondylolisthesis, stenosis, low limb surgery within 3 months of the study, or any surgery involving the lumbar spine, and no history of systemic disease, psychiatric disease, acute trauma, or currently pregnant. Participants were randomly assigned to a cognitive-based functional therapy group or a manual therapy and exercise group. The cognitive therapy group received coaching based on a classification system with four main components including (1) a cognitive component, (2) specific movement exercises designed to normalize maladaptive movement behaviors (3), targeted functional integration of activities in their daily life that were reported to be provocative or avoided (4), and a tailored physical activity program. Session length was 30-50 min, performed 1x/1-3 weeks (average 7.7 total sessions). The manual therapy group received treatment based on an experienced manual therapist's discretion, including joint mobilization or manipulations applied to the spine or pelvis and most patients received motor control exercise (including a home exercise program). Session length was 30-50 min, performed 1x/1-3 weeks (average 8 total sessions). Outcome measures included the Oswestry disability index (ODI), subjective pain intensity (pain), anxiety, and depression were measured with the Hopkins Symptoms Checklist (HSCL-25), fear-avoidance beliefs questionnaire (FABQ), patient satisfaction, range of motion, sick leave days, with re-assessment immediately following treatment and during a 12-month follow-up. The cognitive-based functional therapy group exhibited statistically larger improvements for the ODI, (HSCL-25), FABQ, and patient satisfaction, and the manual therapy and exercise group exhibited fewer sick-leave days and larger improvements in ROM. Again, the two interventions compare very different intervention plans, and the findings imply that the cognitive-based functional therapy group exhibited larger improvements on cognitive tests, whereas the manual therapy and exercise group exhibited larger improvements on objective measures (14). In summary, these studies imply that a combination of PNE and specific physical interventions may be superior to some combinations of manual therapy/modalities and exercise; however, the design of the studies in this section prevented determining correlations between outcomes and any single intervention. Author's note, if the other studies in this review demonstrated that PNE resulted in reliably superior outcomes, then it may have been reasonable to assume that PNE had a significant effect on the outcomes in these studies. However, since the majority of the research demonstrates that PNE is not reliably effective, it is likely more reasonable to assume that the other interventions had a larger influence on outcomes.

Pain Neuroscience Education (PNE) with and without Exercise

The following studies investigate the "opposite" methodology, comparing outcomes following PNE with and without the addition of exercise. An RCT by Fernandes et al. compared 109 patients (age: 60 – 95 years) with symptomatic hip osteoarthritis, and no history of total hip replacement, knee osteoarthritis, knee pain, low back pain, lower extremity dysfunction, rheumatoid arthritis, osteoporosis, cancer, or cardiovascular disease. Participants were randomly assigned to a patient education-only group or patient education and supervised exercise group. Outcome measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC pain, stiffness, and physical function), health-related quality of life questionnaire, and modified Norwegian Physical Activity Score for Elderly (PASE), with a 16-month follow-up. The findings demonstrated both groups exhibited similar reductions in WOMAC pain, WOMAC stiffness, and PACE scores. The exercise group exhibited larger improvements in WOMAC physical function over the 16-month follow-up period compared to the patient education-only group (15). An RCT by Stewart et al. compared 134 patients (age: 43.3 ± 14.7 years) who had been diagnosed with a grade I-III whiplash-associated disorder due to an accident within the previous month, “mildly” disabled, with significant pain, and no history of previous neck surgery, nerve root compromise, serious pathology, depressive symptoms, contraindications to exercise, and was not receiving physiotherapy for the neck during the time of the study. Participants were randomly assigned to an advice group or an exercise and advice group. Advice included education, reassurance, and encouragement to resume light activity, and exercise included 1 hour of submaximal functional activities, aerobic exercise, stretches, speed, endurance, and coordination exercises, and trunk and limb strengthening exercises for 12 sessions in 6 weeks. Outcome measures included disability, health-related quality of life, global perceived effect, and pain intensity during reassessment at 6 weeks and 1 year. The findings demonstrated that the exercise and advice group exhibited significantly larger improvements in disability scores, health-related quality of life scores, and greater global perceived effects during re-assessment at 6 weeks, and exercise was more effective for patients with higher baseline pain and disability (16). These studies demonstrate that adding exercise to PNE significantly improves physical function, disability, health-related quality of life, global perceived effect, and pain intensity.

• Potentially Flawed Study Although this study uses a similar study design as those discussed previously in this section, the study has a significant methodological flaw. An RCT by Ryan et al. compared 38 males and females (age: 18 - 65 years) with non-specific low back pain for longer than 3 months and no history of back surgery, physical therapy within the past 3 months, no involvement in regular sports activities (2x or more/week) for the past 6 months, clinically assessed nerve root irritation, fractures, non-back related musculoskeletal problems, pregnancy in the past year, or a positive response to red flag questions indicating a more serious pathology such as malignancy. Participants were randomly assigned to a pain education group, or a pain education and exercise group. The pain education group received 2.5 hours of pain biology education. The pain education plus exercise group received 2.5 hours of pain biology education and 6 group exercise classes over 8 weeks (note, that only 60% of the participants in the exercise group attended at least 3 of the training sessions). Outcome measures were assessed pre-intervention, post-intervention, and during a 3-month follow-up, and included the Roland Morris Disability Questionnaire, Tampa scale of Kinesiophobia, pain, pain self-efficacy, pain-related fear, the sit-to-stand test, the fifty-foot walk test, and the 5 min walk test. The findings demonstrated that both groups exhibited statistically similar improvements in pain and pain self-efficacy. Further, neither group exhibited statistically significant changes in outcomes for additional outcome measures. Note, that 6 exercise sessions over 8 weeks is not sufficient frequency for statistically significant improvements from exercise, and this study reported that only 60% of the participants in the exercise group attended at least 3 of the training sessions. In short, this study has serious methodological flaws, and if it is evidence for anything, it is the limited efficacy of pain education to improve Roland Morris Disability Questionnaire scores, the Tampa scale of Kinesiophobia, pain, the sit-to-stand test, the fifty-foot walk test, and the 5 min walk test, etc (17).

Pain Neuroscience Education (PNE) With and Without Exercise and Manual Therapy

Again, the following studies investigate the "opposite" methodology of the studies above, comparing outcomes following PNE with and without the addition of manual therapy. An RCT by Bronfort et al. compared 192 patients (age: 21 years or older) experiencing back-related leg pain, with radiating pain into the proximal or distal portion of the lower extremity for at least 4 weeks, with no history of neurological deficits, cauda equina syndrome, spinal fractures, stenosis, osteoporosis, surgical lumbar fusion, lumbar surgery, chronic pain syndrome, visceral diseases, blood clotting disorders, inflammatory tissue changes, pregnancy, substance abuse, or receiving treatment for leg pain or low back pain. Participants were randomly assigned to home exercise and advice with or without spinal manipulation. The home exercise included lumbar flexion and extension in standing, seated, and lying positions for 25 reps/set, 1 set/exercise, 3 sessions/day; as well as, pelvic tilts, quadrupeds, bridging, crunches, and side bridges for 8-12 reps/set, 1 set/session, and 1 session/every other day. The spinal manipulation plus home exercise group received 10-20 mins of high-velocity/low amplitude manipulations and/or low-velocity and variable amplitude mobilizations, stretching, ischemic compression, and hot/cold packs. Outcome measures included back-related leg pain, global pain, patient satisfaction, and medication use at 12 weeks and 1 year. The findings demonstrated that the addition of spinal manipulation resulted in larger improvement in back-related leg pain at 12 weeks, and larger improvements in global pain, patient satisfaction, and medication use at 52 weeks (18). In two publications Niemisto et al. compared 204 patients (age: 24 - 46 years) with chronic low back pain for at least 3 months and an Oswestry disability index score greater than 16%, with no history of systemic disease, spinal infection, previous spinal operations, vertebral fractures within the last 6 months, sciatica with a straight leg raise, or spinal rehabilitation during the time of the study. The participants were randomly assigned to a pain education group (25-page educational booklet) or a combined treatment group receiving pain education, manual therapy, and exercise. Manual therapy and exercise included 4 sessions, 1x/week, 60 min/session of muscle energy technique (MET) targeting the biceps femoris, rectus femoris, iliopsoas, and/or gluteal muscles, as well as isometric transverse abdominis stabilization (drawing-in) exercises. Outcome measures included pain intensity using a visual analog scale (VAS) from 0 - 100, the Oswestry Low Back Pain Disability Questionnaire, the Finnish Depression Questionnaire, frequency of low-back pain experienced, days on sick leave, health-related quality of life, costs of healthcare consumption, and productivity costs at 5 and 12 months. The findings demonstrated the manual therapy and exercise group exhibited significantly larger reductions in pain intensity, self-rated disability scores, and fewer days of sick leave; however, severe affective distress was correlated with a worse response to combined treatment. There were no statistically significant differences between groups for health-related quality of life scores, healthcare consumption costs, or productivity costs (19, 20). In summary, these studies demonstrate that the addition of exercise and/or manual therapy to patient education and advice may result in significantly larger improvements in pain, function, disability, quality of life, and/or range of motion. This implies that if PNE is included in an intervention plan, it should be accompanied by manual therapy and/or exercise.

Related Courses:

• Overhead Squat Assessment: Sign Clusters and Compensation Patterns
• Joint Mobilization and Manipulation: Introduction
• Muscle Fiber Dysfunction and Trigger Points
• Transverse Abdominis Activation

Additional Therapy Articles:

• You Can Palpate The Psoas
• What causes the "popping" noise when you crack a joint? (Does it improve joint manipulation outcomes?)
• Myths About Sacroiliac Joint (SIJ) Motion, Palpation, Assessment, and Treatment

Bibliography

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