The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain


      Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain.


      To evaluate the evidence for the effectiveness of neuroscience education (NE) for pain, disability, anxiety, and stress in chronic musculoskeletal (MSK) pain.

      Data Sources

      Systematic searches were conducted on Biomed Central,, CINAHL, the Cochrane Library, NLM Central Gateway, OVID, ProQuest (Digital Dissertations), PsycInfo, PubMed/Medline, ScienceDirect, and Web of Science. Secondary searching (PEARLing) was undertaken, whereby reference lists of the selected articles were reviewed for additional references not identified in the primary search.

      Study Selection

      All experimental studies including randomized controlled trials (RCTs), nonrandomized clinical trials, and case series evaluating the effect of NE on pain, disability, anxiety, and stress for chronic MSK pain were considered for inclusion. Additional limitations: studies published in English, published within the last 10 years, and patients older than 18 years. No limitations were set on specific outcome measures of pain, disability, anxiety, and stress.

      Data Extraction

      Data were extracted using the participants, interventions, comparison, and outcomes (PICO) approach.

      Data Synthesis

      Methodological quality was assessed by 2 reviewers using the Critical Review Form–Quantitative Studies. This review includes 8 studies comprising 6 high-quality RCTs, 1 pseudo-RCT, and 1 comparative study involving 401 subjects. Most articles were of good quality, with no studies rated as poor or fair. Heterogeneity across the studies with respect to participants, interventions evaluated, and outcome measures used prevented meta-analyses. Narrative synthesis of results, based on effect size, established compelling evidence that NE may be effective in reducing pain ratings, increasing function, addressing catastrophization, and improving movement in chronic MSK pain.


      For chronic MSK pain disorders, there is compelling evidence that an educational strategy addressing neurophysiology and neurobiology of pain can have a positive effect on pain, disability, catastrophization, and physical performance.

      Key Words

      List of Abbreviations:

      BPPT (brachial plexus provocation test), CFS (chronic fatigue syndrome), CLBP (chronic low back pain), CONSORT (Consolidated Standards of Reporting Trials), LBP (low back pain), MSK (musculoskeletal), NE (neuroscience education), NPRS (numeric pain rating scale), PCI (Pain Coping Inventory), PCS (Pain Catastrophization Scale), PICO (participants, interventions, comparison, outcomes), PPT (pressure pain threshold), PSEQ (Pain Self-Efficacy Questionnaire), RCT (randomized controlled trial), RMDQ (Roland Morris Disability Questionnaire), SLR (straight leg raise), SOPA(R) (Survey of Pain Attitudes (Revised)), TSK (Tampa Scale of Kinesiophobia), VAS (visual analog scale), WAD (whiplash-associated disorders)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bernard A.M.
        • Wright S.W.
        Chronic pain in the ED.
        Am J Emerg Med. 2004; 22: 444-447
        • Mortimer M.
        • Ahlberg G.
        To seek or not to seek?.
        Scand J Public Health. 2003; 31: 194-203
        • Louw A.
        • Louw Q.
        • Crous L.C.C.
        Preoperative education for lumbar surgery for radiculopathy.
        S Afr J Physiother. 2009; 65: 3-8
        • Brox J.I.
        • Storheim K.
        • Grotle M.
        • Tveito T.H.
        • Indahl A.
        • Eriksen H.R.
        Systematic review of back schools, brief education, and fear-avoidance training for chronic low back pain.
        Spine J. 2008; 8: 948-958
        • Liddle S.D.
        • Gracey J.H.
        • Baxter G.D.
        Advice for the management of low back pain: a systematic review of randomised controlled trials.
        Man Ther. 2007; 12: 310-327
        • Heymans M.W.
        • van Tulder M.W.
        • Esmail R.
        • Bombardier C.
        • Koes B.W.
        Back schools for nonspecific low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group.
        Spine. 2005; 30: 2153-2163
        • Engers A.
        • Jellema P.
        • Wensing M.
        • van der Windt D.A.
        • Grol R.
        • van Tulder M.W.
        Individual patient education for low back pain.
        Cochrane Database Syst Rev. 2008; (CD004057)
        • Udermann B.E.
        • Spratt K.F.
        • Donelson R.G.
        • Mayer J.
        • Graves J.E.
        • Tillotson J.
        Can a patient educational book change behavior and reduce pain in chronic low back pain patients?.
        Spine J. 2004; 4: 425-435
        • Cohen J.E.
        • Goel V.
        • Frank J.W.
        • Bombardier C.
        • Peloso P.
        • Guillemin F.
        Group education interventions for people with low back pain.
        Spine. 1994; 19: 1214-1222
        • Gross A.R.
        • Aker P.D.
        • Goldsmith C.H.
        • Peloso P.
        Patient education for mechanical neck disorders.
        Cochrane Database Syst Rev. 2000; (CD000962)
        • Maier-Riehle B.
        • Harter M.
        The effects of back schools–a meta-analysis.
        Int J Rehabil Res. 2001; 24: 199-206
        • Butler D.
        • Moseley G.
        Explain pain.
        Noigroup, Adelaide2003
        • Moseley G.L.
        A pain neuromatrix approach to patients with chronic pain.
        Man Ther. 2003; 8: 130-140
        • Moseley G.L.
        Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain.
        Eur J Pain. 2004; 8: 39-45
        • Koes B.W.
        • van Tulder M.W.
        • van der Windt W.M.
        • Bouter L.M.
        The efficacy of back schools: a review of randomized clinical trials.
        J Clin Epidemiol. 1994; 47: 851-862
        • Waddell G.
        The back pain revolution.
        2nd ed. Churchill Livingstone, Edinburgh2004
        • Nachemson A.L.
        Newest knowledge of low back pain.
        Clin Orthop. 1992; : 8-20
        • Poiraudeau S.
        • Rannou F.
        • Baron G.
        • et al.
        Fear-avoidance beliefs about back pain in patients with subacute low back pain.
        Pain. 2006; 124: 305-311
        • Hirsch M.S.
        • Liebert R.M.
        The physical and psychological experience of pain: the effects of labeling and cold pressor temperature on three pain measures in college women.
        Pain. 1998; 77: 41-48
        • Burton A.K.
        • Waddell G.
        • Tillotson K.M.
        • Summerton N.
        Information and advice to patients with back pain can have a positive effect.
        Spine. 1999; 24: 2484-2491
        • Moseley G.L.
        Joining forces—combining cognition-targeted motor control training with group or individual pain physiology education: a successful treatment for chronic low back pain.
        J Man Manip Therap. 2003; 11: 88-94
        • Moseley G.L.
        Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI evaluation of a single patient with chronic low back pain.
        Aust J Physiother. 2005; 51: 49-52
        • Moseley G.L.
        • Hodges P.W.
        • Nicholas M.K.
        A randomized controlled trial of intensive neurophysiology education in chronic low back pain.
        Clin J Pain. 2004; 20: 324-330
        • Ryan C.G.
        • Gray H.G.
        • Newton M.
        • Granat M.H.
        Pain biology education and exercise classes compared to pain biology education alone for individuals with chronic low back pain: a pilot randomised controlled trial.
        Man Ther. 2010; 15: 382-387
        • Meeus M.
        • Nijs J.
        • Van Oosterwijck J.
        • Van Alsenoy V.
        • Truijen S.
        Pain physiology education improves pain beliefs in patients with chronic fatigue syndrome compared with pacing and self-management education: a double-blind randomized controlled trial.
        Arch Phys Med Rehabil. 2010; 91: 1153-1159
        • Moseley G.L.
        Unravelling the barriers to reconceptualisation of the problem in chronic pain: the actual and perceived ability of patients and health professionals to understand the neurophysiology.
        J Pain. 2003; 4: 184-189
        • Moseley L.
        Combined physiotherapy and education is efficacious for chronic low back pain.
        Aust J Physiother. 2002; 48: 297-302
        • Law M.
        • Stewart D.
        • Letts L.
        • Pollock N.
        • Bosch J.
        • Westmoreland M.
        Critical review form–quantitative studies.
        (Accessed November 17, 2011)
        • Petticrew M.
        Why certain systematic reviews reach uncertain conclusions.
        BMJ. 2003; 326: 756-758
        • Law M.
        • Stewart D.
        • Pollock N.
        • Letts L.
        • Bosch J.
        • Westmoreland M.
        Guidelines for critical review form–quantitative studies, 1998.
        (Accessed November 17, 2011)
        • Bialocerkowski A.
        • Kurlowicz K.
        • Vladusick S.
        • Grimmer K.
        Effectiveness of primary conservative management for infants with obstetric brachial plexus palsy.
        Int J Evid Based Healthc. 2005; 3: 27-44
        • Daly A.E.
        • Bialocerkowski A.E.
        Does evidence support physiotherapy management of adult complex regional pain syndrome type one?.
        Eur J Pain. 2009; 13: 339-353
        • Altman D.G.
        • Schulz K.F.
        • Moher D.
        • et al.
        The revised CONSORT statement for reporting randomized trials: explanation and elaboration.
        Ann Intern Med. 2001; 134: 663-694
        • Moher D.
        • Schulz K.F.
        • Altman D.G.
        The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials.
        Ann Intern Med. 2001; 134: 657-662
        • Ezzo J.
        • Berman B.
        • Hadhazy V.A.
        • Jadad A.R.
        • Lao L.
        • Singh B.B.
        Is acupuncture effective for the treatment of chronic pain?.
        Pain. 2000; 86: 217-225
        • Fernandez-de-Las-Penas C.
        • Alonso-Blanco C.
        • Cuadrado M.L.
        • Miangolarra J.C.
        • Barriga F.J.
        • Pareja J.A.
        Are manual therapies effective in reducing pain from tension-type headache?.
        Clin J Pain. 2006; 22: 278-285
        • Stone P.W.
        Popping the (PICO) question in research and evidence-based practice.
        Appl Nurs Res. 2002; 15: 197-198
        • Herbert R.D.
        How to estimate treatment effects from reports of clinical trials.
        Aust J Physiother. 2000; 46: 229-235
        • Farrar J.T.
        • Young Jr, J.P.
        • LaMoreaux L.
        • Werth J.L.
        • Poole R.M.
        Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale.
        Pain. 2001; 94: 149-158
        • Ferreira M.L.
        • Ferreira P.H.
        • Latimer J.
        • Herbert R.
        • Maher C.G.
        Does spinal manipulative therapy help people with chronic low back pain?.
        Aust J Physiother. 2002; 48: 277-284
        • Van Oosterwijck J.
        • Nijs J.
        • Meeus M.
        • et al.
        Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: a pilot study.
        J Rehabil Res Dev. 2011; 48: 43-58
        • Cherkin D.C.
        • Deyo R.A.
        • Battie M.
        • Street J.
        • Barlow W.
        A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain.
        N Engl J Med. 1998; 339: 1021-1029
        • Klaber Moffett J.A.
        • Torgeson D.
        • Bell-Syer S.
        • Jackson D.L.
        • Llewellyn-Phillips H.
        Randomised controlled trial of exercise for low back pain: clinical outcomes, costs and preferences.
        BMJ. 1999; 319: 279-283
        • Coppieters M.W.
        • Alshami A.M.
        • Babri A.S.
        • Souvlis T.
        • Kippers V.
        • Hodges P.W.
        Strain and excursion of the sciatic, tibial, and plantar nerves during a modified straight leg raising test.
        J Orthop Res. 2006; 24: 1883-1889
        • Puentedura E.J.
        • Brooksby C.L.
        • Wallmann H.W.
        • Landers M.R.
        Rehabilitation following lumbosacral percutaneous nucleoplasty: a case report.
        J Orthop Sports Phys Ther. 2009; 40: 214-224
        • Leal M.
        • Sterling M.
        • Elliott J.A.
        combined manual therapy and pain educational treatment approach of a patient with elevated psychosocial variables and persistent neck pain: A case report.
        2008 (Seattle, WA.)
        • Weiner B.K.
        Spine update: the biopsychosocial model and spine care.
        Spine. 2008; 33: 219-223
        • Henrotin Y.E.
        • Cedraschi C.
        • Duplan B.
        • Bazin T.
        • Duquesnoy B.
        Information and low back pain management: a systematic review.
        Spine. 2006; 31: E326-E334
        • Houben R.M.
        • Ostelo R.W.
        • Vlaeyen J.W.
        • Wolters P.M.
        • Peters M.
        • Stomp-van den Berg S.G.
        Health care providers' orientations towards common low back pain predict perceived harmfulness of physical activities and recommendations regarding return to normal activity.
        Eur J Pain. 2005; 9: 173-183
        • Spoto M.M.
        • Collins J.
        Physiotherapy diagnosis in clinical practice: a survey of orthopaedic certified specialists in the USA.
        Physiother Res Int. 2008; 13: 31-41
        • Morr S.
        • Shanti N.
        • Carrer A.
        • Kubeck J.
        • Gerling M.C.
        Quality of information concerning cervical disc herniation on the internet.
        Spine J. 2010; 10: 350-354
        • Greene D.L.
        • Appel A.J.
        • Reinert S.E.
        • Palumbo M.A.
        Lumbar disc herniation: evaluation of information on the internet.
        Spine (Phila Pa 1976). 2005; 30: 826-829
        • Melzack R.
        Pain and the neuromatrix in the brain.
        J Dent Educ. 2001; 65: 1378-1382
        • Dean E.
        Physical therapy in the 21st century (part II): evidence-based practice within the context of evidence-informed practice.
        Physiother Theory Pract. 2009; 25: 354-368
        • Murphy B.P.
        • Greathouse D.
        • Matsui I.
        Primary care physical therapy practice models.
        J Orthop Sports Phys Ther. 2005; 35: 699-707
        • Childs J.D.
        • Whitman J.M.
        Advancing physical therapy practice: the accountable practitioner.
        J Orthop Sports Phys Ther. 2005; 35: 624-627
        • Busch A.J.
        • Barber K.A.
        • Overend T.J.
        • Peloso P.M.
        • Schachter C.L.
        Exercise for treating fibromyalgia syndrome.
        Cochrane Database Syst Rev. 2007; (CD003786)
        • Nijs J.
        • Van Houdenhove B.
        From acute musculoskeletal pain to chronic widespread pain and fibromyalgia: application of pain neurophysiology in manual therapy practice.
        Man Ther. 2009; 14: 3-12
        • Meeus M.
        • Nijs J.
        • Meirleir K.D.
        Chronic musculoskeletal pain in patients with the chronic fatigue syndrome: a systematic review.
        Eur J Pain. 2007; 11: 377-386
        • Adam J.A.
        • Khaw F.M.
        • Thomson R.G.
        • Gregg P.J.
        • Llewellyn-Thomas H.A.
        Patient decision aids in joint replacement surgery: a literature review and an opinion survey of consultant orthopaedic surgeons.
        Ann R Coll Surg Engl. 2008; 90: 198-207
        • McGregor A.H.
        • Burton A.K.
        • Sell P.
        • Waddell G.
        The development of an evidence-based patient booklet for patients undergoing lumbar discectomy and un-instrumented decompression.
        Eur Spine J. 2007; 16: 339-346
        • Coudeyre E.
        • Demaille-Wlodyka S.
        • Poizat S.
        • Burton K.
        • Hamonet M.A.
        • Revel M.
        • Poiraudeau S.
        Could a simple educational intervention modify beliefs about whiplash?.
        Ann Readapt Med Phys. 2007; 50 (545-51): 552-557
        • Carvalho H.
        Active teaching and learning for a deeper understanding of physiology.
        Adv Physiol Educ. 2009; 33: 132-133
        • Crabtree J.L.
        • Royeen C.B.
        • Mu K.
        The effects of learning through discussion in a course in occupational therapy: a search for deep learning.
        J Allied Health. 2001; 30: 243-247
        • Sandberg J.
        • Barnard Y.
        Deep learning is difficult.
        Instr Sci. 1997; 25: 15-36
        • Scholten I.
        • Keeves J.P.
        • Lawson M.J.
        Validation of a free response test of deep learning about the normal swallowing process.
        Higher Education. 2002; 44: 233-255
        • Wittmann-Price R.A.
        • Godshall M.
        Strategies to promote deep learning in clinical nursing courses.
        Nurse Educ. 2009; 34: 214-216
        • Moseley G.L.
        • Brhyn L.
        • Ilowiecki M.
        • Solstad K.
        • Hodges P.W.
        The threat of predictable and unpredictable pain: differential effects on central nervous system processing?.
        Aust J Physiother. 2003; 49: 263-267
        • Moseley G.L.
        • Nicholas M.K.
        • Hodges P.W.
        Does anticipation of back pain predispose to back trouble?.
        Brain. 2004; 127: 2339-2347
        • Cleland J.A.
        • Fritz J.M.
        • Childs J.D.
        Psychometric properties of the Fear-Avoidance Beliefs Questionnaire and Tampa Scale of Kinesiophobia in patients with neck pain.
        Am J Phys Med Rehabil. 2008; 87: 109-117
        • Thomas J.S.
        • France C.R.
        Pain-related fear is associated with avoidance of spinal motion during recovery from low back pain.
        Spine. 2007; 32: E460-E466
        • Smeets R.J.
        A comparison of the relationship between depression, perceived disability, and physical performance in persons with chronic pain: a comment on Alschuler et al (2008).
        Eur J Pain. 2009; 13 (author reply 111-2): 109-110
        • Smeets R.J.
        Do lumbar stabilising exercises reduce pain and disability in patients with recurrent low back pain?.
        Aust J Physiother. 2009; 55: 138
        • Lotze M.
        • Erb M.
        • Flor H.
        • Huelsman E.
        fMRI evaluation of somatotopic representation in human primary motor cortex.
        Neuroimage. 2000; 11: 473-481
        • Peyron R.
        • Laurent B.
        • Garcia-Larrea L.
        Functional imaging of brain responses to pain.
        Neurophysiol Clin. 2000; 30: 263-288
        • Morley S.
        • Eccleston C.
        • Williams A.
        Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache.
        Pain. 1999; 80: 1-13
        • Garcia-Campayo J.
        • Serrano-Blanco A.
        • Rodero B.
        • et al.
        Effectiveness of the psychological and pharmacological treatment of catastrophization in patients with fibromyalgia: a randomized controlled trial.
        Trials. 2009; 10: 24
        • Wallin M.K.
        • Raak R.I.
        Quality of life in subgroups of individuals with whiplash-associated disorders.
        Eur J Pain. 2008; 12: 842-849
        • Turk D.C.
        Combining somatic and psychosocial treatment for chronic pain patients: perhaps 1 + 1 does = 3.
        Clin J Pain. 2001; 17: 281-283
        • Kerns R.D.
        • Wagner J.
        • Rosenberg R.
        • Haythornthwaite J.
        • Caudill-Slosberg M.
        Identification of subgroups of persons with chronic pain based on profiles on the pain stages of pain questionnaire.
        Pain. 2005; 116: 302-310
        • Meeus M.
        • Nijs J.
        Central sensitization: a biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome.
        Clin Rheumatol. 2007; 26: 465-473
        • LaMontagne L.
        • Hepworth J.T.
        • Salisbury M.H.
        • Cohen F.
        Effects of coping instruction in reducing young adolescents' pain after major spinal surgery.
        Orthop Nurs. 2003; 22: 398-403
        • Walters M.
        • Coad J.
        Preparation of children for spinal surgery: an exploratory study.
        Paediatr Nurs. 2006; 18: 27-29
        • Barton S.
        Which clinical studies provide the best evidence?.
        BMJ. 2000; 321: 255-256
        • Norris S.L.
        • Atkins D.
        Challenges in using nonrandomized studies in systematic reviews of treatment interventions.
        Ann Intern Med. 2005; 142: 1112-1119
        • Fukuda K.
        • Straus S.E.
        • Hickie I.
        • Sharpe M.C.
        • Dobbins J.G.
        • Komaroff A.
        The chronic fatigue syndrome: a comprehensive approach to its definition and study.
        Ann Intern Med. 1994; 121: 953-959
        • Australian National Health and Medical Research Council
        How to review the evidence: systematic identification and review of the scientific literature.
        (Accessed, November 16, 2011)