Author Names
Louwa, A; Farrellb, K; Landersc, M; Barclayb, M; Goodmanb, E; Gillundb, J; McCaffrey, S; Timmerman, L
Reviewer Name
Elizabeth Carey, SPT
Reviewer Affiliation(s)
Duke University, Doctor of Physical Therapy Division
Paper Abstract
Objective: To determine if a neuroplasticity educational explanation for a manual therapy technique will produce a different outcome compared to a traditional mechanical explanation. Methods: Sixty-two patients with chronic low back pain (CLBP) were recruited for the study. Following consent, demographic data were obtained as well as pain ratings for low back pain (LBP) and leg pain (Numeric Pain Rating Scale), disability (Oswestry Disability Index), fear avoidance (Fear-Avoidance-Beliefs Questionnaire), forward flexion (fingertips-to-floor), and straight leg raise (SLR) (inclinometer). Patients were then randomly allocated to receive one of two explanations (neuroplasticity or mechanical), a manual therapy technique to their lumbar spine, followed by post-intervention measurements of LBP, leg pain, forward flexion, and SLR. Results: Sixty-two patients (female 35 [56.5%]), with a mean age of 60.1 years and mean duration of 9.26 years of CLBP participated in the study. There were no statistically significant interactions for LBP (p = .325), leg pain (p = .172), and trunk flexion (p = .818) between the groups, but SLR showed a significant difference in favor of the neuroplasticity explanation (p = .041). Additionally, the neuroplasticity group were 7.2 times (95% confidence interval = 1.8–28.6) more likely to improve beyond the MDC on the SLR than participants in the mechanical group. Discussion: The results of this study show that a neuroplasticity explanation, compared to a traditional biomechanical explanation, resulted in a measurable difference in SLR in patients with CLBP when receiving manual therapy. Future studies need to explore if the increase in SLR correlated to changes in cortical maps of the low back.
NIH Risk of Bias Tool
Quality Assessment of Controlled Intervention Studies
- Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
- Yes
- Was the method of randomization adequate (i.e., use of randomly generated assignment)?
- Yes
- Was the treatment allocation concealed (so that assignments could not be predicted)?
- Yes
- Were study participants and providers blinded to treatment group assignment?
- No
- Were the people assessing the outcomes blinded to the participants’ group assignments?
- Cannot Determine, Not Reported, or Not Applicable
- Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
- Cannot Determine, Not Reported, or Not Applicable
- Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
- Yes
- Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
- Yes
- Was there high adherence to the intervention protocols for each treatment group?
- Yes
- Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
- Yes
- Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
- Yes
- 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?
- Cannot Determine, Not Reported, or Not Applicable
- Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
- Yes
- 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
Explaining treatment techniques and goals to patients using neuroplasticity principles can result in measurable improvements compared to patients receiving biomechanical explanations.
Key Finding #2
When in conjunction with manual therapy, neuroplasticity education improves the straight leg raise test scores for patients with chronic low back pain when compared to similar patients who receive biomechanical education.
Key Finding #3
There was no difference indicated between the test and control group’s responses to education and treatment in low back pain rating, leg pain, and forward flexion.
Key Finding #4
Although the straight leg raise exceeded the MCD with neuroplastic education, there is no MCID for the SLR test. Therefore, it is unknown if the change is clinically meaningful.
Please provide your summary of the paper
The goal of this randomized clinical trial was to compare the effects of manual therapy along with a biomechanical explanation (control group) or a neuroplasticity explanation (experimental group) on low back pain, leg pain, forward flexion, and a straight leg raise. 62 patients with chronic low back pain participated in the study, and provided initial ratings for low back pain, leg pain, disability, fear avoidance, forward flexion, and straight leg raise. All patients received grade 2 central posterior-anterior mobilizations while in prone for 10 minutes. Half of the participants received an explanation of the manual therapy technique in biomedical terms (here is a picture of your low back, when you move, some of these segments stiffen up, I’m going to use my hands to make each level move,” etc.) while the other half in neuroplasticity terms (Here’s a picture of your brain where there’s a map telling you where your body parts are, moving less makes these parts of the brain work less and become blurry which can cause pain, I’m going to do some manual techniques on your back to help your brain sharpen these maps, etc.). Post-intervention, the same outcome measures were taken again. There was no significance between groups for low back pain leg pain, and trunk flexion, but the straight leg raise showed significant improvement for the neuroplasticity group. For the SLR, the neuroplasticity group participants exceeded the MCD from pre-test and was 7.2 times more likely to improve beyond the MCD compared to the biomechanical explanation group. Further studies are needed to explore whether this increase in SLR scores correlated with cortical map changes of the low back, and long-term effects of neuroplasticity education.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
Based on this clinical trial, I believe that principles of neuroplasticity can be incorporated into patient education to increase the likelihood of better outcomes in patients. Especially for conditions like chronic low back pain, finding a adaptation to treatment with the possibility of improving outcomes should be highly considered and further investigated. Neither explanation would have been successful without the use of manual therapy on the lumbar spine. The specific benefit to the straight leg raise in this study could be related to the rapid response of neurodynamics, as has been seen in other studies on pain neuroscience education. Further research is needed to test the ability of longer-term education on other aspects of physical examination, especially when the fear of movement is a limitation in progress.
