Authors
1 Faculty of Physical Education and Sports Sciences, Shahid Beheshti University, Tehran
2 Faculty of Physical Education and Sports Sciences, Kharazmi University, Tehran
3 Faculty of Physical Education and Sports Sciences, Allameh Tabatabaee university, Tehran, Iran.
Abstract
Aim and Background:
Low back pain is considered a major cause of functional disability, reduced quality of life, fear of pain and movement, reduced motor control, and absenteeism from work in many countries (1,2). Disorders associated with low back pain are not unidimensional and involve multiple biological, social, and psychological aspects of the individual. The cause of low back pain can include changes in lifestyle, work environment, physical inactivity, muscle weakness, and decreased flexibility due to muscle imbalances in the lumbopelvic complex (3). Current management of chronic low back pain involves a wide range of different treatments, including education, manual therapy, medication, mobilization, manipulation, electrotherapy, and exercise therapy (6-4). Despite the existence of various therapeutic interventions, including physical and mental therapies, the effect size of conservative treatment approaches for chronic nonspecific low back pain has been small to moderate. This may be due to the lack of consideration of multidimensional psychosocial and biological factors, as well as the absence of personalized exercise programs for patients (7,8). The pain neuroscience education approach is a new cognitive behavioral therapy intervention that attempts to reduce pain and disability by explaining the physiology of pain to the patient to change maladaptive cognitive patterns during functional activities (9). Despite many studies aiming to add pain neuroscience education to various therapeutic interventions and exercises, the question remains as to which exercise program, combined with this method, produces better results in terms of pain improvement, disability, psychological factors, and functional outcomes. Therefore, a review of the literature in this field seems necessary and can improve low back pain treatment protocols. Therefore, the present study aimed to review the available resources to investigate the effect of combining pain neuroscience education with exercise on pain, functional disability, and psychological factors in patients with chronic low back pain.
Methods:
This study is a narrative review. Articles indexed in the databases Magiran, Irandoc, PubMed, Google Scholar, PEDro, and Scopus were retrieved between 2010 and 2024. The English keywords used included ("non-specific chronic low back pain" OR "chronic low back pain" OR "back pain") AND ("pain neuroscience education" OR "pain education" OR "pain biology education" OR "pain neurophysiology education" OR "pain physiology education" AND ("training" OR "exercise therapy" OR "therapeutic exercise" OR "Physiotherapy" OR "exercise")). The inclusion criteria included valid clinical trial articles indexed in the aforementioned databases, Persian or English-language studies, patients complaining of chronic non-specific low back pain, an age range of 18 to 70 years, and a score equal to or greater than 5 according to the PEDro scale. If participants had low back pain with known causes, combining the pain neuroscience education approach with passive physiotherapy interventions, including manual therapy, mobilization, manipulation, drug therapy, massage therapy, and other interventions separate from exercise therapy, and replication studies were considered as exclusion criteria.
Finding and results:
Eleven articles were found (Figure 1). One study used only pain neuroscience education as a control group (10). Exercise programs included hydrotherapy (11), exercise-based physiotherapy (5,12,13), aerobic and core stability exercises (10), motor control and postural retraining (14), motor control, and core stability (8), group motor control exercises (4), cognitively targeted motor control exercises (15), and corrective exercises (16) and Pilates (17). Seven studies showed a significant reduction in pain in the intervention group compared to the control group (16-4,8,11,13). In three studies, although pain improved, the changes between the two groups were not significant (5,12,17). Finally, in one study, the changes in pain were more significant in the control group compared to the intervention group (10). In three studies, a significant reduction in disability was observed in the intervention group compared to the control group (4,14,16) In eight studies, despite improvement in disability in the intervention group compared to the control group, the between-group changes were not significant (13,15,17-5,8,10). In five studies, fear of movement improved significantly in the intervention group compared to the control group (16-5,12,4). In three studies, despite greater improvement in the intervention group, the between-group changes in fear of movement were not significant (10,11,17). In one study, a significant improvement in pain catastrophizing was observed in the intervention group compared to the control group (16). In contrast, three studies found no significant difference in the pain catastrophizing variable between the two groups (12,13,17). In fear avoidance beliefs, there was a significant improvement in one study (14), and in one study, there was no significant difference between the two groups (4,13). In central pain sensitization, one study showed significant improvement in the intervention group compared to the control group (15), and in one study, the changes between groups were not significant (12). In the self-efficacy variable, in one study, there was significant improvement (14), in another study, there was no significant difference between the two groups (4), and in another study, the control group had a more significant improvement compared to the intervention group (10). Finally, there was no significant difference between the two groups in the depression variable; however, the changes in the intervention group were greater (12).
Discussion and Conclusion:
The results showed that combining the pain neuroscience education approach with exercise programs in the intervention group significantly improved pain (16-4,8,11,13), disability (4,16), fear of movement (5,12,15,16), pain catastrophizing (16), and central pain sensitivity (15). In other studies, despite greater improvement in the intervention group compared to the control group, changes in pain (5,12,17), disability (13,15,17-5,8,10), fear of movement (10,11,17), pain catastrophizing (12,13,17), fear-avoidance beliefs (4,13), depression, central pain sensitivity (12), and self-efficacy (4) were not significant. Rehabilitation and corrective exercise specialists can use this protocol in the treatment of patients with chronic non-specific low back pain. Limitations of the present study include differences in the exercise protocol, time, and dose of pain neuroscience education, and a lack of follow-up. It is suggested that future research should examine the combination of pain neuroscience education with exercise interventions in other common injuries (such as knee pain).
Keywords
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