Pain Neurophysiology Education and Therapeutic Exercise for Patients With Chronic Low Back Pain: A Single-Blind Randomized Controlled Trial

Published:November 11, 2017DOI:



      To assess the effect of a pain neurophysiology education (PNE) program plus therapeutic exercise (TE) for patients with chronic low back pain (CLBP).


      Single-blind randomized controlled trial.


      Private clinic and university.


      Patients with CLBP for ≥6 months (N=56).


      Participants were randomized to receive either a TE program consisting of motor control, stretching, and aerobic exercises (n=28) or the same TE program in addition to a PNE program (n=28), conducted in two 30- to 50-minute sessions in groups of 4 to 6 participants.

      Main Outcomes Measures

      The primary outcome was pain intensity rated on the numerical pain rating scale which was completed immediately after treatment and at 1- and 3-month follow-up. Secondary outcome measures were pressure pain threshold, finger-to-floor distance, Roland-Morris Disability Questionnaire, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, and Patient Global Impression of Change.


      At 3-month follow-up, a large change in pain intensity (numerical pain rating scale: −2.2; −2.93 to −1.28; P<.001; d=1.37) was observed for the PNE plus TE group, and a moderate effect size was observed for the secondary outcome measures.


      Combining PNE with TE resulted in significantly better results for participants with CLBP, with a large effect size, compared with TE alone.


      List of abbreviations:

      CLBP (chronic low back pain), MCID (minimal clinically important difference), NPRS (numerical pain rating scale), PCS (Pain Catastrophizing Scale), PGIC (Patient Global Impression of Change), PNE (pain neurophysiology education), RMDQ (Roland-Morris Disability Questionnaire), TE (therapeutic exercise), TSK-11 (Tampa Scale for Kinesiophobia)
      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


        • Hoy D.
        • Bain C.
        • Williams G.
        • et al.
        A systematic review of the global prevalence of low back pain.
        Arthritis Rheum. 2012; 64: 2028-2037
        • Airaksinen O.
        • Brox J.
        • Cedraschi C.
        • et al.
        Chapter 4. European guidelines for the management of chronic nonspecific low back pain.
        Eur Spine J. 2006; 15 Suppl 2: S192-S300
        • Becker A.
        • Held H.
        • Redaelli M.
        • et al.
        Low back pain in primary care: costs of care and prediction of future health care utilization.
        Spine. 2010; 35: 1714-1720
        • Bernstein I.A.
        • Malik Q.
        • Carville S.
        • Ward S.
        Low back pain and sciatica: summary of NICE guidance.
        BMJ. 2017; 356: i6748
        • Macedo L.G.
        • Maher C.G.
        • Latimer J.
        • McAuley J.H.
        Motor control exercise for persistent, nonspecific low back pain: a systematic review.
        Phys Ther. 2009; 89: 9-25
        • Saragiotto B.T.
        • Maher C.G.
        • Yamato T.P.
        • et al.
        Motor control exercise for chronic non-specific low-back pain.
        Cochrane Database Syst Rev. 2016; : CD012004
        • Lluch Girbes E.
        • Nijs J.
        • Torres-Cueco R.
        • Lopez Cubas C.
        Pain treatment for patients with osteoarthritis and central sensitization.
        Phys Ther. 2013; 93: 842-851
        • Keller A.
        • Hayden J.
        • Bombardier C.
        • Van Tulder M.
        Effect sizes of non-surgical treatments of non-specific low-back pain.
        Eur Spine J. 2007; 16: 1776-1788
        • Woolf C.J.
        Central sensitization: implications for the diagnosis and treatment of pain.
        Pain. 2011; 152: S2-S15
        • 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 Ther. 2003; 11: 88-94
        • Moseley G.L.
        • Nicholas M.K.
        • Hodges P.W.
        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
        • Louw A.
        • Diener I.
        • Butler D.S.
        • Puentedura E.J.
        The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain.
        Arch Phys Med Rehabil. 2011; 92: 2041-2056
        • Louw A.
        • Zimney K.
        • Puentedura E.J.
        • Diener I.
        The efficacy of pain neuroscience education on musculoskeletal pain: a systematic review of the literature.
        Physiother Theory Pract. 2016; 32: 332-355
        • Leventhal H.
        • Brissette I.
        • Leventhal E.A.
        The common-sense model of self-regulation (CSM): a dynamic framework for understanding illness self-management.
        J Behav Med. 2016; 39: 935-946
        • Spinhoven P.
        • Kuile M.
        • Kole-Snijders A.M.
        • Mansfeld M.H.
        • Ouden D.
        • Vlaeyen J.W.
        Catastrophizing and internal pain control as mediators of outcome in the multidisciplinary treatment of chronic low back pain.
        Eur J Pain. 2004; 8: 211-219
        • Moseley L.
        Combined physiotherapy and education is efficacious for chronic low back pain.
        Aust J Physiother. 2002; 48: 297-302
        • 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
        • 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
        • Van Oosterwijck J.
        • Meeus M.
        • Paul L.
        • et al.
        Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial.
        Clin J Pain. 2013; 29: 873-882
        • Moher D.
        • Hopewell S.
        • Schulz K.F.
        • et al.
        CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials.
        J Clin Epidemiol. 2010; 63: e1-e37
        • Dolphens M.
        • Nijs J.
        • Cagnie B.
        • et al.
        Efficacy of a modern neuroscience approach versus usual care evidence-based physiotherapy on pain, disability and brain characteristics in chronic spinal pain patients: protocol of a randomized clinical trial.
        BMC Musculoskelet Disord. 2014; 15: 149
        • Dworkin R.H.
        • Turk D.C.
        • Farrar J.T.
        • et al.
        Core outcome measures for chronic pain clinical trials: IMMPACT recommendations.
        Pain. 2005; 113: 9-19
        • Childs J.D.
        • Piva S.R.
        • Fritz J.M.
        Responsiveness of the numeric pain rating scale in patients with low back pain.
        Spine. 2005; 30: 1331-1334
        • Stratford P.W.
        • Binkley J.
        • Solomon P.
        • Gill C.
        • Finch E.
        Assessing change over time in patients with low back pain.
        Phys Ther. 1994; 74: 528-533
        • Kovacs F.M.
        • Llobera J.
        • Gil Del Real M.T.
        • et al.
        Validation of the spanish version of the Roland-Morris questionnaire.
        Spine (Phila Pa 1976). 2002; 27: 538-542
        • Roland M.
        • Fairbank J.
        The Roland–Morris disability questionnaire and the Oswestry disability questionnaire.
        Spine. 2000; 25: 3115-3124
        • Campayo J.G.
        • Rodero B.
        • Alda M.
        • Sobradiel N.
        • Montero J.
        • Moreno S.
        [Validation of the Spanish version of the Pain Catastrophizing Scale in fibromyalgia].
        Med Clin (Barc). 2008; 131 ([Spanish]): 487-492
        • Hapidou E.G.
        • O'Brien M.A.
        • Pierrynowski M.R.
        • de las Heras E.
        • Patel M.
        • Patla T.
        Fear and avoidance of movement in people with chronic pain: psychometric properties of the 11-item Tampa Scale for Kinesiophobia (TSK-11).
        Physiother Can. 2012; 64: 235-241
        • Gómez-Pérez L.
        • López-Martínez A.E.
        • Ruiz-Párraga G.T.
        Psychometric properties of the Spanish version of the Tampa Scale for Kinesiophobia (TSK).
        J Pain. 2011; 12: 425-435
        • Ostelo R.W.
        • de Vet H.C.
        Clinically important outcomes in low back pain.
        Best Pract Res Clin Rheumatol. 2005; 19: 593-607
        • Perret C.
        • Poiraudeau S.
        • Fermanian J.
        • Colau M.M.
        • Benhamou M.A.
        • Revel M.
        Validity, reliability, and responsiveness of the fingertip-to-floor test.
        Arch Phys Med Rehabil. 2001; 82: 1566-1570
        • Rolke R.
        • Baron R.
        • Maier C.A.
        • et al.
        Quantitative sensory testing in the German Research Network on Neuropathic Pain (DFNS): standardized protocol and reference values.
        Pain. 2006; 123: 231-243
        • Kosek E.
        • Ekholm J.
        • Hansson P.
        Pressure pain thresholds in different tissues in one body region. The influence of skin sensitivity in pressure algometry.
        Scand J Rehabil Med. 1999; 31: 89-93
        • Chesterton L.S.
        • Sim J.
        • Wright C.C.
        • Foster N.E.
        Interrater reliability of algometry in measuring pressure pain thresholds in healthy humans, using multiple raters.
        Clin J Pain. 2007; 23: 760-766
        • Costa L.O.
        • Maher C.G.
        • Latimer J.
        • et al.
        Motor control exercise for chronic low back pain: a randomized placebo-controlled trial.
        Phys Ther. 2009; 89: 1275-1286
        • Norris C.M.
        La guía completa de los estiramientos.
        Editorial Paidotribo, Barcelona2007
        • Butler D.S.
        • Moseley G.L.
        Sunyata. Explain pain.
        Noigroup Publications, Adelaide2003
        • Faul F.
        • Erdfelder E.
        • Lang A.
        • Buchner A.
        G* Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences.
        Behav Res Methods. 2007; 39: 175-191
        • Pires D.
        • Cruz E.B.
        • Caeiro C.
        Aquatic exercise and pain neurophysiology education versus aquatic exercise alone for patients with chronic low back pain: a randomized controlled trial.
        Clin Rehabil. 2015; 29: 538-547
        • Liddle S.D.
        • Baxter G.D.
        • Gracey J.H.
        Exercise and chronic low back pain: what works?.
        Pain. 2004; 107: 176-190
        • Clarke C.L.
        • Ryan C.G.
        • Martin D.J.
        Pain neurophysiology education for the management of individuals with chronic low back pain: a systematic review and meta-analysis.
        Man Ther. 2011; 16: 544-549
        • Van Oosterwijck J.
        • Nijs J.
        • Meeus M.
        • Paul L.
        Evidence for central sensitization in chronic whiplash: a systematic literature review.
        Eur J Pain. 2013; 17: 299-312
        • Louw A.
        • Diener I.
        • Landers M.R.
        • Puentedura E.J.
        Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up.
        Spine (Phila Pa 1976). 2014; 39: 1449-1457
        • Puentedura E.J.
        • Louw A.
        A neuroscience approach to managing athletes with low back pain.
        Phys Ther Sport. 2012; 13: 123-133
        • 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
        • Moseley G.L.
        • Butler D.S.
        Fifteen years of explaining pain: the past, present, and future.
        J Pain. 2015; 16: 807-813
        • Neblett R.
        • Cohen H.
        • Choi Y.
        • et al.
        The Central Sensitization Inventory (CSI): establishing clinically significant values for identifying central sensitivity syndromes in an outpatient chronic pain sample.
        J Pain. 2013; 14: 438-445
        • Girbés E.L.
        • Meeus M.
        • Baert I.
        • Nijs J.
        Balancing “hands-on” with “hands-off” physical therapy interventions for the treatment of central sensitization pain in osteoarthritis.
        Man Ther. 2015; 20: 349-352
        • Nijs J.
        • Meeus M.
        • Cagnie B.
        • et al.
        A modern neuroscience approach to chronic spinal pain: combining pain neuroscience education with cognition-targeted motor control training.
        Phys Ther. 2014; 94: 730-738
        • Nijs J.
        • Girbés E.L.
        • Lundberg M.
        • Malfliet A.
        • Sterling M.
        Exercise therapy for chronic musculoskeletal pain: innovation by altering pain memories.
        Man Ther. 2015; 20: 216-220