Author Names

Tavares, F., Rossiter, J., Lima, G., Oliveira, L., Cavalcante, W., Ávila, M., George, S., Chaves, T.

Reviewer Name

Elise Giannotti, SPT

Reviewer Affiliation(s)

Duke University School of Medicine, Doctor of Physical Therapy Division

 

Paper Abstract

Background: Spinal manipulative therapy (SMT) demonstrates small effects on pain intensity in low back pain. Combining SMT with a psychosocial intervention like pain neuroscience education (PNE) could promote additional effect.  Objectives: To evaluate the additional effect of PNE when combined to SMT on pain intensity and low back pain-related disability in patients with chronic low back pain (CLBP).  Method: One hundred and four patients with CLBP of both sexes aged between 18 and 55 years were treated with PNE + SMT compared to SMT alone. The primary outcome measures were pain intensity and disability post-treatment (4 weeks). Secondary outcomes were fear-avoidance beliefs, global perceived effect of improvement, and pain self-efficacy. Results were obtained immediately post-treatment and at three follow-ups (30-days, 90-days, and 180-days).  Results: No significant between-group difference was observed for pain intensity and disability post-treatment. In contrast, our results showed a significantly longer additional effect for the group treated with SMT + PNE for the following outcomes: pain intensity (change baseline to 90 day follow-up = 0.90 [95% CI= 1.76, 0.4] and change baseline to 180 day follow-up = 1.19 [95% CI= 2.06, 0.32]) and low back pain-related disability, global perceived effect of improvement and pain self-efficacy (180th day follow-up).  Conclusion: The results of this trial suggest the addition of PNE to SMT did not bring any additional effect on pain intensity and disability in the short term, but SMT + PNE can result in longer-lasting effects in patients with CLBP and that such an effect could be related to a possible mediator effect of pain self-efficacy.

 

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

  1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
  • Yes
  1. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
  • Yes
  1. Was the treatment allocation concealed (so that assignments could not be predicted)?
  • Yes
  1. Were study participants and providers blinded to treatment group assignment?
  • Yes
  1. Were the people assessing the outcomes blinded to the participants’ group assignments?
  • Cannot Determine, Not Reported, or Not Applicable
  1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
  • Yes
  1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
  • Yes
  1. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
  • Yes
  1. Was there high adherence to the intervention protocols for each treatment group?
  • Yes
  1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
  • Yes
  1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
  • Yes
  1. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
  • Yes
  1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
  • Yes
  1. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
  • Yes

 

Key Finding #1

There was no significant difference between subjects receiving only spinal manipulative therapy (SMT) and subjects receiving both pain neuroscience education (PNE) and SMT at the immediate post-treatment assessment.

Key Finding #2

At the 90day and 180day assessments, those subjects that received both PNE and SMT were found to have lower pain intensity ratings on NPRS, lower scores on the ODI describing their low back pain-related disability, and better pain self-efficacy scores on the questionnaire. PNE may be effective for long-term results.

Key Finding #3

Based on this design, the subjects only received PNE for the first two sessions out of eight sessions. The PNE consisted of two thorough, 40minute sessions with powerpoints, discussions, and animated videos. One may be able to conclude that education in relatively small, yet thorough amounts is also effective for the long-term success of a patient.

 

Please provide your summary of the paper

This study performed a randomized controlled trial to determine whether the addition of pain neuroscience education (PNE) would be beneficial to those who experience chronic low back pain (CLBP). By including this psychosocial aspect to their intervention, researchers hypothesized the group receiving PNE + spinal manipulative therapy (SMT) would see greater reduction in both pain intensity and LBP disability reports. Immediate post-treatment assessments did not support their hypothesis, instead it found there was no significant difference between the group who received PNE + SMT and the group who only received SMT.  Pushing forward, researchers collected data at the 90day mark and the 180day mark. There, they found significant differences. The PNE + SMT group showed long term impact through just two sessions of PNE at the start of the study. This study concluded long term effects of the psychosocial intervention positively affects the quality of life of those experiencing CLBP.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

This study translates easily into practice by recognizing some patients with CLBP will have long-term success if physical therapists can provide education on pain neuroscience. Knowing that in this study the PNE + SMT group only received PNE in the first two sessions and followed with only SMT for the next six sessions, it is possible to see long term effects with relatively small, yet thorough amounts of education. Bringing that concept to clinical practice, we may be able to help patients the most by guiding them to understand their pain: why it occurs, what it really tells us, and what biologically happens to make pain emerge. Based on this research, by educating our patients on pain science, we can help them see success in their future.