Study review: A randomized controlled trial of intensive neurophysiology education in chronic low back pain
Moseley, G.L. et al. (2002), Clin J Pain 20: 324-330
Firstly, I can only access the abstract, unfortunately I live well under the poverty line and do not have the finances to buy all of these studies so that I can read the detail. Personally, I think this stuff should be freely available, but there you are. I don’t make the rules.
This one costs $47.00. I believe this is USD. So that would be about $69 AUD.
But on to the study. It says:
Objectives: Cognitive-behavioral pain management programs typically achieve improvements in pain cognitions, disability, and physical performance. However, it is not known whether the neurophysiology education component of such programs contributes to these outcomes. In chronic low back pain patients, we investigated the effect of neurophysiology education on cognitions, disability, and physical performance.
So they want to find out if the ‘education’ part of the Cognitive behavioural therapy (CBT) is having an effect on its own. Cool. Good question.
Methods: This study was a blinded randomized controlled trial. Individual education sessions on neurophysiology of pain (experimental group) and back anatomy and physiology (control group) were conducted by trained physical therapist educators. Cognitions were evaluated using the Survey of Pain Attitudes (revised) (SOPA(R)), and the Pain Catastrophizing Scale (PCS). Behavioral measures included the Roland Morris Disability Questionnaire (RMDQ), and 3 physical performance tasks; (1) straight leg raise (SLR), (2) forward bending range, and (3) an abdominal “drawing-in” task, which provides a measure of voluntary activation of the deep abdominal muscles. Methodological checks evaluated non-specific effects of intervention.
Cool. So they’re measuring both behavioural and physical factors. But. Problem. They don’t say how many people are in the trial…I mean, that’s weird. The size of the sample is pretty darned important, so it’s annoying that they don’t mention it. Should be in the abstract, in my opinion. Because if there were a few thousand people in this study that would obviously be far more credible than if there were only a hundred, or less, people involved. I can’t see any reason to omit this information unless it is, in fact, a very small study. Which makes it less credible.
Even more important are a few other things, namely, how much pain were these people in?
Something that I find all the time is that studies use a sample of people in mild/moderate pain, they select for people in mild/moderate pain, but then they claim that their treatment works on severe pain. Which is a lie. Or a very intentional twisting of the truth. There’s a huge difference between treating mild moderate and severe pain. Very different treatments. You don’t treat a papercut the same way you treat a broken foot!
But onwards to the results:
Results: There was a significant treatment effect on the SOPA(R), PCS, SLR, and forward bending. There was a statistically significant effect on RMDQ; however, the size of this effect was small and probably not clinically meaningful.
So their attitudes to pain improved, they catastrophised less, and they were able to perform a straight legged raise and a forward bend more easily.
But unfortunately, the effect size isn’t quantified other than ‘significant’. I mean, ‘significant’ is pretty good but I’d like to have seen the actual numbers. It’s telling though that it doesn’t specifically say that they reduced their pain, just that they did better on a straight leg test and forward bending. And, importantly, it didn’t decrease their disability at all.
So what did they conclude? Sorry, they called it ‘discussion’:
Education about pain neurophysiology changes pain cognitions and physical performance but is insufficient by itself to obtain a change in perceived disability. The results suggest that pain neurophysiology education, but not back school type education, should be included in a wider pain management approach
Education about pain neurophysiology changes pain cognitions and physical performance.
So the education changes the way people think about pain. And it changes physical performance. That’s pretty vague. It also says nothing about time frame. They didn’t follow these people up and figure out if the improved straight leg test and forward bending was a lasting effect. Or if it was just immediately after they’d learned about pain.
Kind of a major omission. If the effect doesn’t last, you can’t really call it an effective treatment, can you?
Also, it did nothing to change perceived disability. Seems like it didn’t do much of anything at all.
But still, I think this study is interesting but there isn’t anywhere near enough detail for me to decide if it’s of any value. This is the kind of study that should inspire more research NOT the kind of study that is used as the FIRST reference in a book, offered up as evidence that pain neuroscience education reduces pain and disability. The study does NOT support that conclusion, the ‘evidence’ is just not there.
I can’t believe this is what their first reference says. I’ve heard Lorimer on podcasts saying that by 2004 or so he had plenty of evidence that pain education reduces pain, he was more than satisfied that this was proven.
Hard to believe two neuroscientists figured THIS was enough evidence to put their theory out there, and to inflict this on pain patients. He’s got a very warped idea of what evidence is.
I’m shocked that this is what he calls ‘convincing’.
Rather disturbingly, this study is cited by 112 other studies. All of them using this as evidence that pain education reduces pain. Why in the world would anyone cite this study as proof? It doesn’t show anything! This is not science; this is myth building. This is exactly how myths are perpetuated, seems no one actually READS the citations. They just believe what the paper in front of them is saying. But you can’t do that, clearly.
Surely the other eleven studies are more thorough and offer actual evidence. Because this convinces me of nothing, except that possibly a major con has been committed and no one notices. Except the pain patients who have biological pain, structural pain, pain caused by disease and nerve damage, people who live with SEVERE pain who have had their safe effective medications taken away in favour of ‘Explain Pain’.
So out of 12 studies used as evidence, we are 0 for 12. Moving on…