In patients with chronic spinal pain, neuroscience education coupled with cognitive motor control training may result in greater improvements in pain, central sensitization, and disability compared with standard physiotherapy, according to findings published in JAMA Neurology.

Finding efficacious therapies for chronic spinal pain is crucial to lowering healthcare costs and improving patient satisfaction. Nonsurgical treatments have had limited effectiveness, and evidence is lacking regarding the efficacy of alternative nonbiomedical therapeutic measures.

For this multicenter randomized clinical trial ( identifier: NCT02098005), a total of 120 patients (39.2% men; mean age, 40.2 years) with nonspecific chronic spinal pain were enrolled. Participants were randomly assigned to receive either an experimental treatment (pain neuroscience education plus cognition-targeted motor control training) or a control treatment (standard education + exercise).

Primary endpoints were pain, assessed with the Numeric Rating Scale and the Central Sensitization Inventory, as well as with pressure pain thresholds, and conditioned pain modulation and function, assessed by the 36-Item Short Form Health Survey (SF36) and the Pain Disability Index. Secondary endpoints were gray matter morphologic changes and pain cognition (ie, pain catastrophizing, kinesiophobia, and pain awareness).

Study participants receiving experimental vs control treatment had higher pressure pain thresholds (estimated marginal mean [EMM], 0.971; 95% CI, −0.028 to 1.970), lower Pain Disability Index scores (EMM, −5.113; 95% CI, −9.994 to −0.232), and higher scores on the SF36 physical component (EMM, 39.263; 95% CI, 9.644-66.882) at 3 months. At 6 months, patients in the experimental treatment group had reduced Central Sensitization Inventory scores (EMM, −5.684; 95% CI, −10.589 to −0.780), reduced Pain Disability Index scores (EMM, −6.351; 95% CI, −11.153 to −1.550), and improved scores on the mental and physical components of the SF36 (EMM, 36.496; 95% CI, 7.998-64.995; and EMM, 53.007; 95% CI, 23.805-82.209; respectively) compared with individuals in the control group.

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At 12 months, individuals in the experimental group had lower Central Sensitization Inventory scores (EMM, −6.053; 95% CI, −10.781 to −1.324), decreased Pain Disability Index scores (EMM, −5.779; 95% CI, −10.340 to −1.217), and improved SF36 physical component scores (EMM, 32.208; 95% CI, 2.402-62.014).

No subcortical gray matter morphologic changes were detected on magnetic resonance imaging. Pain cognition measures showed improvement in kinesiophobia, but not in pain catastrophizing.

Study strengths included being the first of its kind to examine morphology as well as the effects of education combined with cognitive training, a large sample size drawn from multiple centers, balanced treatment groups, sufficient statistical power, use of best-evidence physiotherapy as a control, reliance on published study protocols, and application of blinded outcome assessments through 12 months. Study limitations included a lack of statistical correction for hormonal influences.

“The presence of significant clinical improvements without changes at the brain level challenges the clinical relevance of these alterations in gray matter morphologic findings in people with [nonspecific chronic spinal pain],” concluded the study authors. “This finding emphasizes the need for a shift toward a biopsychosocial focus (ie, cognition and perceptions underlying the pain problem), rather than maintaining a focus toward a purely biomedical origin when treating these patients in clinical practice,” they added.

Dr Nijs reported being coauthor of a Dutch book for clinicians on pain neuroscience education, but the royalties for that book are collected by the Vrije Universiteit Brussel and not him personally.

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Malfliet A, Kregel J, Coppieters I, et al. Effect of pain neuroscience education combined with cognition-targeted motor control training on chronic spinal pain [published online April 16, 2018]. JAMA Neurol. doi: 10.1001/jamaneurol.2018.0492