Research Review By Dr. Demetry Assimakopoulos©


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Date Posted:

October 2016

Study Title:

Combining manual therapy with pain neuroscience education in the treatment of chronic low back pain: A narrative review of the literature


Puentedura EJ & Flynn T

Author's Affiliations:

Department of Physical Therapy, University of Nevada, Las Vegas; School of Physical Therapy, South College, Knoxville, Tennessee, USA

Publication Information:

Physiotherapy Theory and Practice 2016; 32(5): 408-414. DOI: 10.1080/09593985.2016.1194663.

Background Information:

Chronic low back pain (CLBP) is an extremely common condition. In some cases, CLBP can lead to decreased quality of life, excessive healthcare utilization, work absence and long term disability (1-3). Numerous chronic low back pain management guidelines endorse a multitude of treatments, such as supervised exercise, cognitive behavioral therapy (CBT), spinal manipulative therapy (SMT) and multidisciplinary treatment, to name a few.

Pain Neuroscience Education (PNE) is a promising new treatment approach for CLBP. PNE endeavors to teach patients about the neurophysiology and neurobiology of pain, in order to help the patient re-conceptualize their pain experience (4, 5). To date, several RCTs and two systematic reviews have reported improvement in function, catastrophization, disability and pain following PNE (6-10).

Sadly, because of PNE’s therapeutic success, many clinicians have abandoned the use of manual therapy as a possible treatment for CLBP, citing that the application of manual therapy may actually augment the patient’s focus on peripheral nociception and disability. The authors of this narrative literature review sought to discuss the how PNE and manual therapy can be used synergistically in CLBP management.


How Does Manual Therapy Work?

Many researchers theorize that the effects of manual therapy are mediated via a reduction in peripheral nociception, which blunts the output of pain from the brain itself. However, recently, greater attention has been given to top-down-mediated cognitive factors, such as thoughts, beliefs and expectations, which change the patient’s perception of injury, thus leading to a decrease in pain, post-treatment (11, 12). This line of thinking is starkly different than more traditional, biomechanical theories!

Manipulating the Brain: Enhancing Patient Expectations

Exploring and meeting patient expectations for treatment has been shown to improve treatment outcomes (13, 14). This notion stipulates that when a patient expects a treatment to improve their symptoms, they are more likely to experience an improvement (15, 16). This experience is often referred to as the “placebo response.”

In daily clinical practice, manual therapy is not done in a vacuum. Rather, it is delivered alongside a complex set of physical and psychological stimuli that contribute to clinical improvement, such as the patient-therapist relationship, patient needs, personality, psychological state, severity of symptoms, and clinical environment (17, 18). Many patients expect a manual therapist to touch their back, for example. If PNE or other hands-off therapies are solely used, it is likely that the therapist is not meeting the patient’s treatment expectations, and this might contribute to poor clinical results. (REVIEWER’S NOTE: Some chronic pain patients are scared of treatment. In these cases, PNE, other hands-off therapies and/or distraction are key. This is why patient-centred care is so important. Remember to treat the patient, not necessarily their condition.)

Clinicians who are gentle and confident in their skills are generally most liked by chronic pain patients (19). Patient-centred, multi-dimensional therapy where the therapists care, listen and help patients to achieve their goals, generally leads to the best clinical outcomes.

Somatosensory Cortex – Manual Therapy as a Means to Refresh Body Schema Maps

The brain has a fantastic ability to recognize the body as its own. This is achieved through the creation of a body schema, which is defined as “the brain’s dynamic representation of the body, which is sculpted by [one’s] exteroceptive and interoceptive experiences.” Body schema can be disrupted by neglect, avoidance and injury (20), which often manifest as an impairment of tactile acuity, poor body awareness, and pain. Essentially, the cortical areas representing the affected body part become “smudged”. (REVIEWER’S NOTE: The authors are essentially describing the sensory-motor homunculi. In each homunculus, body regions are represented by a concentration of cell bodies. Picture this collection of cell bodies like a piece of property. Each body part has its own piece of property in the homunculus with defined borders. In times of prolonged pain or disuse, these borders can become smudged, which impairs the body’s ability to interpret sensory input, and execute proper motor output. These neurophysiological changes can lead to symptoms such as poor tactile acuity and pain. After a prolonged period, cortical smudging can spread to areas adjacent to the affected body region, leading to spreading pain and other symptoms.)

Recent literature has demonstrated impairments in laterality judgements, body image and tactile acuity in painful areas (21-22). It is thought that retraining laterality (repeatedly judging which direction the low back is bending/twisting, for example) and tactile discrimination (locating touch sensations) can reverse cortical disruption, leading to decreased pain (23).

In a recent case series, Louw et al. (24) showed immediate improvements in chronic low back pain ratings and flexion range of motion with repeated touch discrimination.

An argument can be made that delivery of painless manual therapy to the low back can assist in re-establishing tactile discrimination, and sharpen the homuncular area.

Emerging Evidence Suggests Coupling PNE and Movement Therapies:

In spite of the abovementioned evidence, an argument can be made that delivery of painless manual therapy to the low back can assist in re-establishing tactile discrimination, and sharpen the smudged homunculus. A recent systematic review showed a combination of PNE with movement-based strategies such as exercise/activity and/or manual therapy are superior to PNE alone (25).

Clinical Application & Conclusions:

The function of PNE is to help the patient understand that the degree of pain is not correlated with the extent of tissue injury. This is done in an effort to reconceptualise pain and change their pain experience. It may seem logical to presume that application of manual therapy may bias the CLBP patient towards the false notion that the degree of tissue injury is the most important factor in the creation of pain. However, the authors of this study argued that PNE in combination with manual and movement-based therapies may have a greater analgesic effect than PNE alone.

Clinical commentary: The interesting, and often most frustrating thing about chronic pain management is the fact that every patient is different. We as clinicians cannot use a shotgun, one-size-fits-all approach to treatment!

It is important to acknowledge that the patient’s pain is real; explicitly acknowledging that their pain is real is vitally important, because patients often feel belittled by the suggestion that their “pain is in the brain.” Or “all in their head”. It is also important to ensure that the patient is ready and willing to be educated about the neurobiology and neurophysiology of pain. Otherwise, PNE might be wasted on that patient.

Manual therapy and rehabilitation must be applied in a patient-centred manner. Standard orthopaedic examination and physical treatments are part of the picture. However, the treatment should be guided by patient’s goals and expectations. Actually asking a patient what their expectations are is important – you want to make sure that the patient’s expectations are realistic. Once expectations are established, it is safe to ask the patient what their goals are. Successful treatment depends on achieving those functional goals.

Study Methods:

No methods were mentioned. This was a narrative literature/clinical review, and thus neither statistical analysis nor systematic search strategy were detailed.

Study Strengths / Weaknesses:

  • The authors did not belittle the effect of PNE, and concluded that the individual strategies work better when used in combination.
  • The authors did not discuss when to introduce PNE as a component of therapy. Sometimes, patients aren’t ready to accept that their nervous system has been sensitized or changed, and vehemently believe they have undiagnosed tissue injury, require surgery or additional imaging. Their beliefs and behaviours need to be confronted and more fully understood before their outlook can be positively altered. This distinction is the difference between research and knowledge transfer into daily clinical practice.

Additional References:

  1. Gore M, Sadosky A, Stacey BR, et al. The burden of chronic low back pain: Clinical comorbidities, treatment patterns, and health care costs in usual care settings. Spine 2012; 37: E668–677.
  2. Ibrahim T, Tleyjeh IM, Gabbar O. Surgical versus nonsurgical treatment of chronic low back pain: A meta-analysis of randomised trials. International Orthopaedics 2008; 32: 107–113.
  3. Melloh M, Roder C, Elfering A, et al. Differences across health care systems in outcome and cost-utility of surgical and conservative treatment of chronic low back pain: A study protocol. BMC Musculoskeletal Disorders 2008; 9: 81.
  4. Butler DS & Moseley GL 2013 Explain Pain, 2nd edn. Adelaide, Australia, NOI Publishing.
  5. Louw A, Diener I, Butler DS, et al. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of Physical Medicine and Rehabilitation 2011; 92: 2041–2056.
  6. Clarke CL, Ryan CG, Martin DJ. Pain neurophysiology education for the management of individuals with chronic low back pain: Systematic review and meta-analysis. Manual Therapy 2011; 16: 544–549.
  7. Moseley GL. Combined physiotherapy and education is efficacious for chronic low back pain. Australian Journal of Physiotherapy 2002; 48: 297–302.
  8. Moseley GL. Joining forces – combining cognition targeted motor control training with group or individual pain physiology education: A successful treatment for chronic low back pain. Journal of Manual and Manipulative Therapy 200; 11: 88–94.
  9. Moseley GL. Unraveling the barriers to reconceptualization of the problem in chronic pain: The actual and perceived ability of patients and health professionals to understand the neurophysiology. Journal of Pain 2003; 4: 184– 189.
  10. Moseley GL, Nicholas MK & Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clinical Journal of Pain 2004; 20: 324– 330.
  11. Gifford L. Topical issues in pain 1. 2013. In: Gifford L (ed) Whiplash: Science and Management.
  12. Tiemann L, May ES, Postorino M, et al. Differential neurophysiological correlates of bottom-up and top-down modulations of pain. Pain 2015; 156: 289–296.
  13. Auer CJ, Glombiewski JA, Doering BK, et al. Patients’ expectations predict surgery outcomes: A meta-analysis. International Journal of Behavioral Medicine 2016; 23: 49–62.
  14. Iles RA, Davidson M, Taylor NF, et al. Systematic review of the ability of recovery expectations to predict outcomes in non-chronic non-specific low back pain. Journal of Occupational Rehabilitation 2009; 19: 25–40.
  15. Bishop MD, Bialosky JE, Cleland JA. Patient expectations of benefit from common interventions for low back pain and effects on outcome: secondary analysis of a clinical trial of manual therapy interventions. Journal of Manual and Manipulative Therapy 2011; 19: 20–25.
  16. Ross S & Buckalew LW. Placebo agentry: Assessment of drug and placebo effects. In: White L, Tursky B, Schwartz GE (eds) Placebo: Theory, Research, and Mechanisms 1985; pp 67–82. New York, Guilford.
  17. Di Blasi Z, Harkness E, Ernst E, et al. Influence of context effects on health outcomes: A systematic review. Lancet 2001; 357 (9258): 757–762.
  18. Edwards I, Jones M, Carr J, et al. Clinical reasoning strategies in physical therapy. Physical Therapy 2004; 84: 312–330.
  19. Maihöfner C, Handwerker HO, Neundörfer B, et al. Patterns of cortical reorganization in complex regional pain syndrome. Neurology 2003; 61: 1707–1715.
  20. Bowering KJ, Butler DS, Fulton IJ, et al. Motor imagery in people with a history of back pain, current back pain, both, or neither. Clinical Journal of Pain 2014; 30: 1070–1075.
  21. Moseley GL. Why do people with complex regional pain syndrome take longer to recognize their affected hand? Neurology 2004; 62: 2182–2186.
  22. Moseley GL. I can’t find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain 2008; 140: 239–243.
  23. Moseley GL & Wiech K. The effect of tactile discrimination training is enhanced when patients watch the reflected image of their unaffected limb during training. Pain 2009; 144: 314–319.
  24. Louw A, Farrell K, Wettach L, et al. Immediate effects of sensory discrimination for chronic low back pain: A case series. 2015; New Zealand Journal of Physiotherapy 43(2): 58–63.
  25. Louw A, Zimney K, Puentedura EJ, et al. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice 2016; 32: 332–355.