STUDY: Can you attack back pain with knowledge bombs?

If you’d never heard of this idea, it might sound crazy to you: maybe knowledge is a pain-killer.

What if you could treat chronic low back pain just by teaching people that it doesn’t actually have much to do with whatever’s going on with spines? That it’s more a matter of pain getting wound up by fear, anxiety, exhaustion, and immobility?

Could just understanding do the job? It sounds a bit implausible. No one doubts that it’s helpful in various ways to be well-informed about a diagnosis, but it seems like a bit of a reach that it would be properly medicinal.

But that is the big idea of “pain neuroscience education” (PNE), one of the hottest hypotheses in the modern rehab business (see Mind Over Pain). There is a modest body of evidence on this topic, pointing every which way so far.

Kayode Eyumi as Roll Safe in “Hood Documentary.” (No, it’s not Eddie Murphy.)

A PNE test

Adenis et al. is a new direct test of the effect of PNE compared to more conventional education. They studied 88 middle-aged patients, 60% women, with year-old low back pain. Everyone did a multidisciplinary rehabilitation program (MRP).

Half added old-school “back school” education to their MRP, doubtless thrilling stuff: knowledge bombs about “spinal physiology” and ergonomics and the hazards of poor posture. If this combo was a meal, it would be fried eggs, limp bacon, and greasy hash browns. It’s not clear that it would be nourishing at all.

The other half got PNE with their MRP: “I’ll have the smoked salmon eggs benny.” And they got plenty of it: eight 30-minute sessions. Although the one-week duration could be considered a weakness, surely PNE can work its magic in four hours of indoctrination in a specific way of thinking about back pain. Surely?

The objective was to help the patient understand that their pain was related more to neuro-immune sensitization (maintained by multiple modifiable biopsychosocial factors, including perceived threats) than to the health of their tissue … Visuals and educational content were closely based on the following PNE media (amongst others): Explain Pain (Butler and Moseley, 2003), Everyone has Back Pain (Louw et al., 2015), Recovery Strategies (Lehman), and Retrain Pain (Retrain pain).

The authors assumed that PNE would be better, and so my hats off to them for honestly reporting what must have been a disappointing result.

PNE didn’t win

PNE was ever-so-slightly better, but the difference was “not statistically significant.” Everyone got better, of course, because back pain studies always show groups of people drifting in the direction of recovery — but there was no real difference in how fast or far they drifted.

The results of the present study of an MRP did not demonstrate a statistically significant difference between … groups with regard to various outcomes, including pain, fear-avoidance beliefs, catastrophizing, kinesiophobia, anxiety, and depression.

I think the most glaring flaw here is that PNE was somewhat at odds with the very typical rehab program that everyone did, contradicting it in some ways rather than harmonizing with it. They researchers made some effort to tweak the MRP so that it was less of a clash, but still … maybe the result would have been different if the PNE group had just gotten PNE.

Or maybe not. Because PNE is always superimposed on a background of more conventional rehab ideas — they’re impossible to avoid! So this way of testing it is realistic instead of ideal.

This isn’t a last-word study, not by a long shot, but it’s certainly a discouraging word for PNE fans. But patients with stubborn chronic pain are not PNE fans.