Tegner H, Frederiksen P, Esbensen BA, et al. Neurophysiological Pain Education for Patients With Chronic Low Back Pain: A Systematic Review and Meta-Analysis. Clin J Pain. 2018 Aug;34(8):778-786. doi: 10.1097/AJP.0000000000000594.
Discipline Area Score
Rehab Clinician (OT/PT) 6 / 7
Physician 5 / 7

OBJECTIVE: To evaluate the effect of neurophysiological pain education (NPE) for patients with chronic low back pain (CLBP).

METHODS: A systematic search was performed in 6 electronic databases. Eligible randomized-controlled trials were those with at least 50 % of patients with CLBP and in which NPE was compared with no intervention or usual care. Methodological quality was assessed independently by 2 of the authors using the Cochrane Collaboration Risk of Bias Tool. The effect of NPE was summarized in a random effect meta-analysis for pain, disability, and behavioral attitudes. Effect was estimated as weighted mean difference (WMD) if outcomes were on the same scale or as standardized mean difference (SMD). The overall quality of evidence was evaluated according to GRADE guidelines.

RESULTS: Seven randomized-controlled trial studies (6 low and 1 high quality) were included. Statistically significant differences in pain, in favor of NPE, were found after treatment, WMD=-1.03 (95% confidence interval [CI], -0.55 to -1.52), and after 3 months, WMD=-1.09 (95% CI, -2.17 to 0.00). Furthermore statistically significant lower disability was found in the NPE group after treatment, SMD=-0.47 (95% CI, -0.80 to -0.13) and after 3 months SMD=-0.38 (95% CI, -0.74 to -0.02). The difference in favor of NPE in reduction in Tampa Scale of Kinesiophobia was not statistically significant, WMD=-5.73 (95% CI, -13.60 to 2.14) and after 3 months WMD=-0.94 (95% CI, -6.28 to 4.40).

DISCUSSION: There was moderate evidence supporting the hypothesis that NPE has a small to moderate effect on pain and low evidence of a small to moderate effect on disability immediately after the intervention. NPE has a small to moderate effect on pain and disability at 3 months follow-up in patients with CLBP.

Comments from MORE raters

Physician rater

Primary care providers will likely find this information about NPE useful especially if they have access to physical therapists or others who can provide this service. While the impact is modest, the condition is quite common and many patients have exhausted other treatment strategies.

Rehab Clinician (OT/PT) rater

The issue of appropriate care for individuals with chronic low back pain is always topical, and the role of pain education is increasingly more relevant to the discussion. This is especially true as physiotherapists have traditionally taken more of a mechanical view of low back pain. This review examines the current evidence on the incorporation of neurophysiological pain education and to a typical physiotherapy approach of hands-on treatment and active exercise. If nothing else, the study illustrates the relatively poor quality of recent research and points to improvements that may be made in future research endeavors. There was moderate evidence that the incorporation of neurophysiological pain education to typical treatment has a a small to moderate effect on pain and low evidence that it has an effect on disability. Individuals who treat patients with chronic low back pain will find this review a good summary of the existing research.

Rehab Clinician (OT/PT) rater

I find the article interesting and recommendable because the methodical procedure has been clearly described, even if the results are not very clear. The results also show that NPE seems easy to implement, but it is essential for the PT and OT practitioners to have a good understanding of theory of pain neurosciences. As well, it's important that the practitioner needs pedagogical skills to teach the NPE to the individual client.

Rehab Clinician (OT/PT) rater

This article is of limited interest to OTs because we already provide education on the effect of reduced activity on the pain cycle, and because the article itself demonstrated limited effect that patient education has on pain reduction.

Rehab Clinician (OT/PT) rater

This adds good extra evidence from previous work by Louw et al demonstrating a degree of significant effect of pain education in patients, and would be highly relevant given the circumstances of practitioner clinical environment/demographics.

Rehab Clinician (OT/PT) rater

The clinical relevance of this study is 'the NPE intervention may be useful in a clinical context as it is simple to combine it with other interventions, it requires no equipment and has no side effects for the patient. Furthermore, verbal NPE makes it possible to be patient-specific and condition-specific and to answer urgent questions. In most studies included in this review, NPE was given as a supplement only to other interventions. It is interesting that a simple supplement with no side effects can produce a small but significant change in pain and disability'.

Rehab Clinician (OT/PT) rater

I was surprised that there was only a moderate to low effect from pain education for chronic low back pain. That said, it is still another tool that we have when treating low back pain, and the article points out the strengths and weaknesses of pain education.

Rehab Clinician (OT/PT) rater

The authors raise some important points with this review including the paucity of high quality evidence on this important and costly condition. Perhaps high quality RCTs are not feasible and we need to reconsider how to demonstrate effectiveness of care.
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