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Original Investigation
July 2018

Effect of Pain Neuroscience Education Combined With Cognition-Targeted Motor Control Training on Chronic Spinal Pain: A Randomized Clinical Trial

Author Affiliations
  • 1Research Foundation–Flanders, Brussels, Belgium
  • 2Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
  • 3Pain in Motion International Research Group, Brussels, Belgium
  • 4Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Brussels, Belgium
  • 5Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, Ghent University, Campus Heymans, Ghent, Belgium
  • 6Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Campus Drie Eiken, Antwerp, Belgium
JAMA Neurol. 2018;75(7):808-817. doi:10.1001/jamaneurol.2018.0492
Key Points

Question  Can a program of pain neuroscience education combined with cognition-targeted motor control training reduce pain and improve function, gray matter morphologic features, and pain cognitions in individuals with chronic spinal pain?

Findings  Results from this randomized clinical trial of 120 individuals with chronic spinal pain indicate that pain neuroscience education combined with cognition-targeted motor control training is superior to usual care at reducing pain and improving function and pain cognitions. Gray matter morphologic features did not change in response to treatment.

Meaning  Clinically relevant changes in response to effective treatment without changes in gray matter morphologic features question the relevance of the well-established alterations at brain level in individuals with chronic spinal pain.

Abstract

Importance  Effective 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 Participants  Multicenter 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 Relevance  Pain 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

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