Study review: Effect of Intensive Patient Education vs Placebo Patient Education on Outcomes in Patients With Acute Low Back Pain: A Randomized Clinical Trial
Pain neuroscience education is now considered a cornerstone treatment for chronic pain. Unfortunately, the science does not seem to match up with the headlines.
This is one of many studies on pain neuroscience education and its utility as a treatment for acute low back pain and its effect on the development of chronic pain. This study was looking the effect of pain neuroscience education for patients with acute lower back pain who were at high risk of developing chronic pain. See the study details below:
Effect of Intensive Patient Education vs Placebo Patient Education on Outcomes in Patients With Acute Low Back Pain: A Randomized Clinical Trial
Adrian C. Traeger, PhD; Hopin Lee, PhD; Markus Hübscher, PhD; Ian W. Skinner, PhD; G. Lorimer Moseley, PhD; Michael K. Nicholas, PhD; Nicholas Henschke, PhD; Kathryn M. Refshauge, PhD; Fiona M. Blyth, PhD; Chris J. Main; Julia M. Hush, PhD; Serigne Lo, PhD; James H. McAuley, PhD
Question that the study is answering: Is intensive patient education effective as part of first-line care for patients with acute low back pain?
Conclusions and Relevance: Adding 2 hours of patient education to recommended first-line care for patients with acute low back pain did not improve pain outcomes. Clinical guideline recommendations to provide complex and intensive support to high-risk patients with acute low back pain may have been premature.
If all you do is read the question that the study is attempting to answer, and the conclusion, its clear that pain neuroscience education ‘did not improve pain outcomes’. The study even warns that adding pain neuroscience education to clinical guidelines for the treatment of chronic pain may have been premature.
So if you’re pressed for time, you can stop reading right here. Pain neuroscience education is no better than placebo as a treatment of chronic pain, according to this study.
This study was performed in from 2013 to 2015 with follow-up in 2016 and was published in 2019.
One of the co-authors is one of Australia’s eminent pain researchers and most well-known personalities in the chronic pain treatment world, who has built a stratospheric and very lucrative career on the idea that pain neuroscience education is the cornerstone of effective treatment for chronic pain.
This study shows that he has known since at least 2019, probably 2016 if he was paying attention, that pain neuroscience education does NOT improve outcomes for chronic pain. Yet he is still to this day promoting pain neuroscience education, despite clearly knowing it is not an effective treatment.
To quote him in one of his videos “I’ll help you understand your pain. Understanding is important, because it can change how much things hurt, and how much your body can do.”
He knows this is not true. But I’ll write more about him and his work later.
Back to the study. Let’s take a closer look.
What they did is they looked at 202 participants who had acute low back pain and had a high risk of developing chronic lower back pain. They were randomised into two groups, with one group receiving 2 x 1 hour sessions of pain neuroscience education (information on pain and biopsychosocial contributors plus self-management techniques, such as remaining active and pacing) or placebo patient education (active listening, without information or advice). All participants received standard first-line care for acute low back pain from their usual practitioner, which includes reassurance that there is no serious injury, advice not to keep moving as much as possible and not to rest in bed and prescribe simple analgesics if necessary.
They tracked the patients for a year. The primary outcome was pain, that is, did their pain improve? This was assessed at 3 months. The secondary outcome was disability, and they were surveyed at one week, 3 months, 6 months, and 12 months for disability scores.
Their conclusions? ”Adding two hours patient education to recommended first-line care for patients with acute lower back pain did not improve pain outcomes.
So basically, pain neuroscience education made no difference to pain levels. Both groups fared evenly, giving people two hours of pain education did not reduce their pain. At all.
There was a small effect of on the secondary outcome of disability at one week and three months but by six and twelve months this effect had disappeared. The pain neuroscience education had no beneficial effect on disability levels from six months onwards.
What’s interesting, is that prior studies have found that the rate of acute back pain developing into chronic pain is between 15-20%, but in this study, 40% went on to develop chronic pain. So the outcomes in this study were worse than what was expected. This could be explained by the researchers actively seeking out patients who were more likely to develop chronic pain and demonstrates that they succeeded in quality patient selection.
Most participants noted a big drop in pain intensity in the first week. Research shows that most people with non-specific back pain will improve within a week with no intervention, so this is exactly what you would expect. From there on in, the average pain experienced was mild, only a 3-4 on the 10-point pain scale.
So we are not talking about severe pain here. Would pain education be more effective with more severe pain? I find this an interesting question. Pain severity and intensity is often brushed over in studies on chronic pain, which is disingenuous because severe pain and mild pain have very different effects on the patient and require very different treatment strategies.
I believe there are some very good reasons why the study came out the way it did.
Firstly, the fact that both groups came out exactly the same could mostly be attributed to the fact that all patients received basic first line care – reassurance that there was no lasting damage, told to keep moving, not to rest in bed, and to take simple analgesics if needed. In reality, there was no true ‘no education’ component. All participants received basic pain education – they just did not all receive intensive pain neuroscience education.
Rather than showing that pain education does not work, this study is showing that extensive pain neuroscience education offers no benefit over basic pain education. That a simple ten-minute consult with your GP who provides basic education on pain and appropriate strategies to manage that pain is just as effective. The study really says that it is not worth investing in intensive pain neuroscience education programs because the added expense does not deliver better outcomes for the patient.
Why then are most chronic pain patients sent to pain education programs? In some programs, completing group or online pain education programs is a prerequisite for accessing pain management or even speaking with a pain management doctor. This takes time, and there is no evidence that pain education will help. It’s just prolonging the wait time for a consult with a pain management doctor, which if they are in severe pain, they desperately need. Now. Even if their pain is not severe, this is not an evidence-based strategy and is just a time-waster.
The pain neuroscience education and the placebo ‘active listening’ treatments brought exactly the same outcomes. While this does show that pain neuroscience education does not reduce chronic pain, an alternate way to interpret this is that what the participants valued was a respected, knowledgeable, educated and trusted expert spending time with them talking about their pain was what mattered. Whether that talk was educational and teaching about chronic pain neuroscience, or whether it was the therapist employing active listening techniques to allow the participant to talk about their pain in whatever way they wished, both had the same effect.
Most people come to pain management having seen multiple physicians in multiple specialties. The average consultation is brief, and often dismissive. Some patients are disbelieved, some have their pain diminished, some have been called hypochondriacs and malingerers. Some have been referred to psychology and psychiatry and told they are mentally ill. In each arm of the trial, the participants pain was validated. Someone took the time to talk to them, and more importantly, listen to them. The value in the sessions may have been in that validation, rather than any specific narrative or content provided.
To be truly well designed, there needed to have been a third arm to the study, where the patients received only the initial ‘best practice’ treatment from the GP, with no two-hour intervention session of any kind. I am very curious what that would have looked like. Would the arm who received no pain education or validation be any different to the other two arms that did? Impossible to say from this study. I only hope someone will repeat this study with that third option in play to try and measure how much patients value having their pain believed and validated and whether that reduces their pain long-term.
And to be fair, I do also wonder if the pain education sessions perhaps had other positive outcomes that weren’t measured in this trial. A GP providing basic but accurate information on back pain seems to build confidence and that might have flow on effects. Things like patients developing better attitudes and beliefs towards their pain resulting in less seeking of medical care down the track for future injuries of episodes of pain. For example, if you learn the first time that the best thing to do is to keep moving not rest in bed, that no damage has been done and that moving will help the healing process, not harm it, then next time you have back pain you’re going to do those things first, rather than consult your doctor immediately. Only if several weeks have passed or the pain is very severe would educated patients attend their GP for medical help, which should result in reduced seeking of medical care, and lower stress on the health system.
In summary, while I’m not a fan of the ‘pain can be cured by pain education’ bandwagon, I’m not saying pain education is worthless. On the contrary, its very worthwhile. But its effects and its value have been hugely overestimated and overemphasised.
Pain neuroscience education helps some people some of the time. End of story. It is not an effective treatment in and of itself and it should not be a first-line treatment. How much it helps is individual and based on the biopsychosocial makeup of the individual and their pain. It’s very important to note that none of the patients in this study had serious spinal pathology, in fact, “serious pathology” was an exclusion criterion. This means that none of these patients had any serious injury causing their pain.
Pain neuroscience education cannot cure serious physical injury or disease, and I don’t believe researchers have even postulated that it can. But somewhere between research and clinical practice, this message has gotten confused and doctors are abandoning safe and effective pain-relieving medications in favour of pain education programs. And this is where the treatment of chronic pain has gone wildly off the rails.
Chronic pain is made in the brain, yes. Chronic pain is a product of both physical and emotional factors, yes. But some people’s chronic pain is mostly due to pathology, that is biological factors, and less to do with psychosocial factors.
Pain neuroscience is a psychosocial treatment for psychosocial pain and was never intended as a treatment for largely pathological or biological pain. And even where the pain is not pathological, not biological, pain neuroscience education has no effect on chronic pain in isolation. It should only be used in combination with other treatments (e.g. physiotherapy, medications, surgeries and procedures, exercise programs, meditation and mindfulness), and it should not be a first-line treatment.