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. 2023 Mar 15;36(4):376–392. doi: 10.1080/08995605.2023.2188046

Pain neuroscience education improves post-traumatic stress disorder, disability, and pain self-efficacy in veterans and service members with chronic low back pain: Preliminary results from a randomized controlled trial with 12-month follow-up

Timothy M Benedict a,✉, Arthur J Nitz b, Michael K Gambrel c, Adriaan Louw d
PMCID: PMC11197901  PMID: 38913769

ABSTRACT

Post-traumatic stress disorder (PTSD) and chronic low back pain (CLBP) are frequently co-morbid. Some research suggests that PTSD and CLBP may share common neurobiological mechanisms related to stress. Traditional biomedical education may be ineffective for PTSD and CLBP, especially when co-morbid. The purpose of this study is to determine if pain neuroscience education (PNE) is more effective than traditional education in reducing PTSD, disability, pain, and maladaptive beliefs in patients with CLBP. Participants with CLBP and possible PTSD/PTSD-symptoms were recruited for this study. Participants were randomly allocated to a PNE group or a traditional education group. The intervention included 30 minutes of education followed by a standardized exercise program once a week for 4-weeks with a 4 and 8-week follow-up and healthcare utilization assessed at 12-months. Forty-eight participants consented for this research study with 39 allocated to treatment (PNE n = 18, traditional n = 21). PNE participants were more likely to achieve a clinically meaningful reduction in PTSD symptoms and disability at short-term follow-up. At 12-months, the PNE group utilized healthcare with 76% lower costs. In participants with CLBP, PNE may reduce hypervigilance toward pain and improve PTSD symptoms. Participants who received PNE were more confident body-tissues were safe to exercise. These beliefs about pain could contribute to a decrease in perceived disability and healthcare consumption for CLBP.

KEYWORDS: Pain neuroscience education, post-traumatic stress disorder, stress, chronic low back pain

What is the public significance of this article?—This study suggests that pain neuroscience education might benefit military service members who have possible post-traumatic stress and chronic low back pain. Specifically, pain neuroscience education may help military service members achieve adaptive beliefs about pain and post-traumatic stress that improve self-efficacy. In turn, improving beliefs about pain may have contributed to decreased medical cost and utilization over 12-months following an intervention of pain neuroscience education and physical therapy.

Introduction

Individuals with post-traumatic stress disorder (PTSD) are at higher risk for developing chronic low back pain (CLBP; Shaw et al., 2010; Suri et al., 2019). Co-morbid PTSD and CLBP are common among military Service Members (Alschuler & Otis, 2012; Otis et al., 2010; Watrous et al., 2020) and increase the likelihood of separation from the military (Benedict et al., 2019). PTSD is defined as a cluster of symptoms following trauma exposure that includes hypervigilance, negative cognitions, reexperiencing trauma reminders, and avoidance that persist for greater than 30 days (American Psychiatric Association, 2013) whereas CLBP interferes with normal functioning beyond 3 months (Deyo et al., 2014).

Stress dysregulation of the hypothalamic pituitary adrenal (HPA) axis has been implicated in PTSD (Morris et al., 2012) as well as CLBP (Hannibal & Bishop, 2014; Johansson et al., 2008; Muhtz et al., 2013; Sudhaus et al., 2009). Acutely, stress hormones like cortisol can help inhibit nociception and decrease pro-inflammatory cytokines (Hannibal & Bishop, 2014; S. J. Diener et al., 2012). Following chronic stress dysregulation, however, the HPA axis becomes dysfunctional and hypocorticolism ensues (Hannibal & Bishop, 2014). This contributes to a hypervigilant nervous system characteristic of nociplastic pain (Nijs et al., 2021). A hypervigilant nervous system may play a relevant role in maintaining CLBP symptoms (O’Neill et al., 2007; Smart et al., 2012; Wand & O’Connell, 2008). Since hyperarousal is such a critical symptom that also contributes to PTSD (Schell et al., 2004), theories like the neurosensitization model (Miller, 2000) and mutual maintenance (Sharp & Harvey, 2001) that explain the shared neurobiology of PTSD and chronic pain are plausible (Scioli-Salter et al., 2015).

In addition to shared neurobiology, the Fear Avoidance Model (Vlaeyen & Linton, 2012) highlights the impact of hypervigilance and avoidance that are common to both PTSD and chronic pain. Furthermore, if an individual with PTSD and CLBP believes that chronic pain indicates ongoing tissue damage, then according to the common-sense model (Bunzli et al., 2017), this individual would understandably avoid painful activities. In fact, such avoidance beliefs and behaviors are common in the military (Dobscha et al., 2008) and possibly enhanced by co-morbid PTSD and CLBP (Alschuler & Otis, 2012). To reduce avoidance behaviors in Service Members with PTSD and CLBP, pain neuroscience education (PNE) may represent an appropriate education strategy (Benedict et al., 2021). Instead of focusing on anatomy and pathology of body tissues, PNE educates patients about the neurophysiology of pain using stories and metaphors (Gallagher et al., 2013). PNE is effective in several chronic pain conditions like fibromyalgia, CLBP, chronic fatigue syndrome, and chronic neck pain (Louw et al., 2016). Some research proposes that PNE helps decrease the pain experience by top-down modulation of the nervous system by decreasing the threat and perceived danger of on-going pain (Moseley, 2003b; Van Oosterwijck et al., 2013). After PNE, patients may be less likely to believe that persisting pain indicates current tissue damage and harm (Moseley, 2003a). Instead, patients learn that the nervous system can become sensitive and amplify the pain experience even after body tissues have healed.

PNE also aims to decrease the stress response associated with pain and may have a joint effect on the hypervigilance associated with PTSD due to potential threats. In fact, recent theories advocate that incorporating neuroscience-informed therapy should play a central role in treating PTSD (Lanius et al., 2011; Ross et al., 2017). Therefore, some researchers believe that PNE might be a vital treatment that addresses PTSD and chronic pain concurrently (Lumley et al., 2022; Willaert et al., 2021). Some patients feel dismissed and stigmatized when their unexplained pain is described as psychological in nature (Morgan et al., 2016). PNE might help decrease stigma associated with the psychological aspects of chronic pain by offering a legitimate and biological reason for unexplained symptoms (Nijs et al., 2011). PNE might also help improve engagement in psychosocial strategies which are sometimes resisted in patients with co-morbid PTSD and pain (Otis et al., 2009) by explaining the neurobiological link between PTSD and chronic pain (Benedict et al., 2021).

These theoretical outcomes of PNE on PTSD symptoms, however, have not been specifically tested in a clinical trial. Although an interdisciplinary program incorporating PNE demonstrated improved outcomes in a small military cohort with chronic pain, the authors highlighted the need to replicate findings with a randomized controlled trial (Nguyen et al., 2020). Furthermore, the delivery of PNE by physical therapists to influence PTSD symptoms has not been tested. The purpose of this research is to determine if PNE is more effective than traditional back pain and stress management education in reducing post-traumatic stress, disability, pain, and maladaptive beliefs about pain in military Service Members with CLBP attending physical therapy. The research team hypothesized that PNE would be more effective than traditional education for all outcomes.

Materials and methods

Participants

Participants were recruited from physical therapy and behavioral health clinics in a Veterans Affairs Medical Center (VAMC) and at an Active Duty Military Treatment Facility located on an Army base. Although individuals with PTSD were purposefully recruited, a formal PTSD diagnosis was not required for participation.

Military Service Members and Veterans with CLBP (symptoms > 3 months duration; Deyo et al., 2014) were referred to participate in this clinical trial. Participants were included if they were between the ages of 18–65. Subjects were excluded for the following: neurogenic LBP (sensory, motor, and reflex deficits consistent to a nerve root and crossed-straight leg raise that reproduces radicular symptoms; Williams et al., 2012) or back pain consistent with red flags (Downie et al., 2013); bipolar disorder, personality disorder, or schizophrenia (Ising et al., 2012); substance abuse within the last 6 months (Fiellin et al., 2000); unstable suicidal ideation (Posner et al., 2011); spine surgery in the past 12 months; or discharged from physical therapy for LBP within the previous 3 months.

This study was approved by the respective Veterans Affairs (VA) and Department of Defense (DOD) institutional review boards and registered at clinicaltrials.gov (NCT05086159).

Study procedures

After individuals consented to participate in the research study, participants were scheduled to complete baseline testing. After baseline measures, participants were randomized to the experimental (PNE) or control (traditional) group by opening opaque, sealed, consecutively numbered envelopes which were prepared by a researcher not involved in this study. The envelopes were prepared in blocks of 10. Participants were then scheduled and allocated to group assignment and completed a 4-week intervention. The intervention consisted of a 30-minute education session followed by a 15-minute exercise circuit each week. Total intervention time was approximately 60 minutes each week to accommodate transition from education to the exercise circuit. Upon completing the intervention, participants attended follow-up testing at four weeks. Participants returned at eight weeks to complete self-reported outcome measures, at which time Veterans were offered a $30 gift card which was donated by a local restaurant. All measurements were assessed by a physical therapist who was blinded to group allocation. Finally, the principal investigator (PI) performed an electronic medical chart review for all participants who began treatment. Participants were evaluated for 12-months following their enrollment according to their assigned group regardless of whether or not they completed the treatment protocol or attended 4 or 8-week follow-up appointments.

Study variables

PTSD Checklist for DSM 5 (PCL)

The PCL is a 20-item checklist that measures the clusters of symptoms associated with PTSD according to the revised DSM 5 (Hoge et al., 2014; Weathers et al., 2013). Scores range from 0–80 with higher numbers indicating higher PTSD symptomology. The recommended cutoff score for PTSD is 33 (Bovin et al., 2016). Participants were considered to have possible PTSD if they indicated on self-report a PTSD diagnosis and scored ≥33 on the PCL. The minimal clinically important difference (MCID) is at least 10 points (Weathers et al., 2013). Cronbach’s alpha for this study was calculated at .96.

Roland-Morris Disability Questionnaire (RMDQ)

The RMDQ is a subjective measure of disability recommended for LBP (Boissoneault et al., 2017). Users are asked to identify among 24 activities or statements that are influenced by their back pain. The answers provide a score between 0 and 24, with higher scores representing more disability. The RMDQ has acceptable validity, reliability, and responsiveness compared to other disability questionnaires (Davies & Nitz, 2009). The MCID for the RMDQ is a 30% reduction from baseline scores (Ostelo et al., 2008).

Numeric Pain Rating Scale (NPRS)

The NPRS is an 11-point scale used to rate subjective pain intensity. The NPRS has been shown to have good validity and reliability (Hawker et al., 2011). The scale ranges from 0 to 10 and has been shown to have acceptable responsiveness in patients with LBP (Childs et al., 2005). This study’s scale was anchored at 0, “no pain at all,” to 10, “the worst pain you could imagine.” The MCID for the NPRS is 1–2 (Dworkin et al., 2008).

Stressometer

The stressometer is a short, one-item scale that measures patient distress on a scale from 0–10. The stressometer is valid and responsive and correlates with more in-depth assessments of psychological stress (D. A. Ryan et al., 2012; Keegan et al., 2015). A score of 4 or higher is considered positive for moderate distress (Ma et al., 2014).

Pain Catastrophizing Scale (PCS)

The PCS measures pain catastrophizing which is defined as an exaggerated negative appraisal of noxious stimuli (Sullivan et al., 1995). The PCS has good validity and excellent reliability in a LBP population (George et al., 2010). Catastrophizing has been identified as an important construct in both PTSD populations (Ciccone & Kline, 2012) and CLBP patients (Wertli et al., 2014). The MCID for the PCS is 5.05 (Suzuki et al., 2020). Cronbach’s alpha for this study was calculated at .94.

Brief Survey of Pain Attitudes (SOPA-35)

SOPA-35 is a valid, reliable, and sensitive questionnaire that measures beliefs about pain across 7 domains (Jensen et al., 2000). This study was particularly interested in the harm sub-scale (Moseley et al., 2004) to assess whether patient’s beliefs that pain means harm changes after the intervention.

Pain Self-Efficacy Questionnaire (PSEQ)

The PSEQ is a questionnaire that measures an individual’s self-perceived confidence to cope with physical activities “despite the pain” (Nicholas, 1989). Studies demonstrate that individuals who have low self-efficacy have higher disability (Lee et al., 2015). The MCID for the PSEQ is 5 (Chiarotto et al., 2016). Cronbach’s alpha for this study was calculated at .93.

Objective outcome measures

Pain Pressure Threshold (PPT)

Patients were tested in the prone position with a pillow under their shins to achieve approximately 15 degrees of knee flexion. A research physical therapist applied a digital algometer probe (SBMEDIC Electronics, Sweden) with a gradual increase in force 5 cm lateral to the spinous process of L3 of the most symptomatic side until the participant reported the pressure as painful and pressed a button attached to the algometer (Farasyn & Meeusen, 2005; Van Oosterwijck et al., 2013). This procedure was performed three times at the low back and averaged to determine the patient’s PPT with approximately 30 seconds rest between repetitions. The procedure was then performed at the suprascapular region contralateral to the side tested in the low back, mid-way between the posterior border of the acromion and the 7th spinous process of the cervical spine (Neziri et al., 2012; Van Oosterwijck et al., 2013).

Spinal flexion

Participants were asked to bend forward at the waist while keeping their knees straight and attempting to touch the floor (Moseley et al., 2004). The distance from the floor to the patient’s most distal finger-tip was measured to the nearest tenth of a centimeter (cm). Participants were instructed to stop “whenever you feel you need to stop.” Participants completed this procedure two times and the measures were averaged.

Healthcare utilization

Long-term follow-up healthcare utilization was operationalized as any medical appointment in the VA or DOD health system in which a patient sought care or was evaluated for complaints of LBP for 12-months following study enrollment according to a medical provider’s electronic documentation of the visit. After electronic chart review of all participants, a physical therapist who was blinded to group allocation verified each medical encounter and then extracted all current procedural terminology (CPT) codes that were charged for each visit related to LBP. In the Military and Veterans Health Affairs, costs are estimated based on the American Medical Association and Medicare equivalents for CPT codes (Phibbs et al., 2003; United States Department of Veterans Affairs, 2020). CPT codes were then also classified as noninvasive or invasive (surgery, imaging, or injections).

All physical measures were completed by a physical therapist who was blinded to participant treatment-group allocation (reliability testing resulted in Intraclass Coefficient, two-way random with measurements averaged = .93).

Post-program questionnaire

This study adapted a questionnaire to assess the satisfaction and acceptability of the intervention (Pincus et al., 2015) on a numerical scale from 0–10 with 10 indicating “strongly agree” and 0 “strongly disagree” (Supplement 1).

Intervention

Experimental education

Participants attended a PNE session that lasted approximately 30 minutes, once a week for 4-weeks. The education was based on “Why do I Hurt?” (Louw, 2013) and was adapted for military Service Members. The education included content recommended by a systematic review (Louw et al., 2011) and compared the nervous system to a military radar which becomes sensitive and hypervigilant following an attack (Supplement 2). Participants also received a PNE booklet developed for this research and were asked to read through the booklet at home (Benedict et al., 2021). Two therapists (7 years’ experience, ± 2.1) delivered the PNE, one of which was the PI of this study.

Traditional education

Similar to the PNE group, participants attended an education session that lasted approximately 30 minutes, once a week for 4-weeks. The education was based on one traditional “Back School” (Linton & Kamwendo, 1987) session followed by 3 stress management sessions adapted from the National Center for PTSD (National Center for PTSD, 2019). A research panel of mental health specialists and physicians rated the modules from the PTSD Coach (Kuhn et al., 2014) and reviewed the education materials developed to provide traditional and standard of care education for stress and post-traumatic stress symptoms in military members (Supplement 2). Participants in the traditional group also received a booklet that was similar in length to the PNE education. The traditional booklet was from “Afterdeployment.org” (Ruzek et al., 2011). Two therapists (8 years’ experience, ±9.2) delivered the traditional arm of the education. When a therapist was unable to complete a session due to scheduling and availability, the PI substituted and delivered the scheduled session.

Both education programs included recommendations for sleep hygiene (Seyffert et al., 2016), the importance of exercise (Garber et al., 2011), breathing (Schmidt et al., 2013), relaxation techniques (Kwekkeboom & Gretarsdottir, 2006), and setting goals (Supplement 2). To maintain treatment fidelity, physical therapists utilized a printed slide presentation and followed a standardized outline for each participant respective to group assignment. All study procedures were completed in the physical therapy department. Interactions were tested for therapist and site to attempt to account for potential confounding due to therapist or site of treatment.

Exercise program

Immediately following each education session, participants completed an exercise circuit based on the “Back to Fitness” program (Moffett & Frost, 2000). To allow for different activity levels across participants, subjects were given the option of performing an easy, moderate, or difficult exercise in each of the 10 exercises in the program (Supplement 3). Participants performed each exercise for 1-minute each, followed by a 5-minute cool-down period. Participants received an ordinal score for each exercise completed; “1” for easy, “2” for moderate, “3” for difficult, and “0” if they did not complete any of the options for the exercise. Participants’ exercise scores were averaged for all sessions and could receive a total score of 0–30. Higher numbers indicate completion of exercises deemed more difficult and challenging, whereas lower numbers indicate potentially easier and less threatening exercises.

Participants in the research program attended individual education and exercise sessions except for 8 individuals who attended group sessions (PNE, n = 3, Traditional, n = 5).

Analytical approach

Sociodemographic characteristics and baseline measures between the PNE and traditional groups were analyzed with independent t-tests for continuous variables and chi-square for categorical or frequency analysis. Effect sizes were calculated with Cohen’s d (small, d = .2, medium, d = .5, large, d = .8) for continuous variables. Effect sizes for categorical variables are included in Table 1. For primary and secondary outcome measures, data were analyzed with a 2-factor (treatment group and time) repeated measures analysis of variance (ANOVA) using a General Linear Model (GLM) with a pre-treatment, post-treatment, and follow-up design (Rausch et al., 2003). The time-points for this analysis included baseline (pre-treatment), 4-weeks (post-treatment), and 8-weeks (follow-up) to determine the stability of potential treatment effects. A group by time interaction was assessed for outcome measures with a plan for post-hoc testing between groups at 4 and 8-weeks for variables with a significant interaction with Bonferroni correction. As important prognostic factors are recommended to include as covariates (Holmberg & Andersen, 2022), this study also analyzed all repeated measure outcomes adjusting for baseline pain catastrophizing scores as pain catastrophizing consistently affects treatment outcomes for CLBP (Wertli et al., 2014). Due to the potential loss of statistical power and consistent with the study’s randomization scheme, further covariates were not planned (Austin et al., 2010). Effect sizes (η2) were calculated for the group×time interaction (small, η2 = .01, medium, η2 = .06, large, η2 = .14; Portney, 2020). For ease of interpretation, unadjusted, observed means are presented in the tables of this study (Portney, 2020). Physical measures only included two time-points: baseline and 4-weeks. Chi-square frequency analysis with Fisher’s exact test was performed for 4- and 8-week measures to determine the proportion of participants in each group that met the MCID for study variables. Furthermore, a one-way ANOVA between treatment conditions for the post-program questionnaire, exercise completion score, and 12-month healthcare utilization was planned. The Kolmogorov-Smirnov test was used to examine normality of variables prior to analysis. The frequency distributions were also inspected visually for approximate normal distribution. Outcomes that failed to meet normality assumptions were assessed with the non-parametric Mann-Whitney U test. Statistical significance was set at .05 using a 2-tailed test. All data were analyzed with Statistical Package for Social Sciences (IBM, version 26).

Table 1.

Baseline sociodemographic, trauma, and health characteristics of participants.

Characteristic Experimental Group, PNE
n = 18		 Control Group, Traditional
n = 20		 P value Standardized Mean Difference (SMD)/Effect
Age, Years (SD) 37.2 (9.7) 41.7 (11.0) .19 SMD = .43b
Gender, M (%)
F (%)		 15 (83.3%)
3 (16.7%)		 16 (80%)
4 (20%)		 1.0 Phi = .043a
Race
African American (%)
Hispanic (%)
White (%)
2 (11.1%)
3 (16.7%)
13 (72.2%)
3 (15%)
4 (20%)
13 (65%)		 .89 Cramer’s V = .079a
Education, Years (SD) 14.1 (2.1) 13.2 (2.0) .18 SMD = .44b
Service
Army (%)
Navy (%)
Marines (%)
Air Force (%)
14 (77.8%)
2 (11.1%)
2 (11.1%)
0
16 (80%)
0
2 (10%)
2 (10%)		 .25 Cramer’s V = .38a
Previous Deployment (%) 11 (61.1%) 12 (60%) 1.0 Phi = .011a
Previous Trauma (%) 16 (88.9%) 16 (80%) .66 Phi = .12a
PTSD Diagnosis (%) 9 (50%) 7 (35%) .51 Phi = .15a
PCL-5 (0–80) (SD) 40.5 (22.4) 36.6 (21.2) .59 SMD = .18a
Stress (0–10) (SD) 7.1 (2.4) 5.7 (3.0) .12 SMD = .51c
Current Depression (%) 11 (61.1%) 13 (65%) 1.0 Phi = .04a
Duration of LBP, Months (SD) 64.3 (61.3) 102.9 (95.1) .20 SMD = .48b
Co-morbidities, # (SD) 6.6 (5.2) 6.3 (4.7) .83 SMD = .06a
% Service Connected Disability (SD) 45.0 (41.2) 28.5 (37.3) .20 SMD = .42b
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M: Male; F: Female; PTSD: Post-traumatic stress disorder; LBP: Low back pain; SD: Standard deviation. PNE: Pain Neuroscience Education. PCL: Post-traumatic stress disorder checklist.

aSmall difference.

bSmall-to-Medium difference.

cMedium difference.

Power

Based on a medium effect size reported for PNE on disability in the literature, this study used G*Power (3.0) and selected Cohen’s d = 0.67 (Moseley et al., 2004) which determined 58 subjects total were required to find a significant difference between groups at α = .05 and 80% power.

Results

In total, 48 Veterans and Soldiers consented to participate in the research study (Figure 1). After randomization, 6 participants failed to schedule baseline testing or the initial treatment session and were not allocated treatment nor analyzed. The PNE group included 18 participants and 21 participants were allocated to the traditional group (N = 39). For participants who began the treatment protocol, four individuals in the PNE and two in the traditional group discontinued treatment with reasons that can be found in Figure 1. The PNE group had 14 available for 4-week testing and 13 for 8-week while the traditional group had 17 and 19, respectively. For the 12-month long-term follow-up conducted by electronic health record review, the PNE group had 18 participants and the traditional group 20. Table 1 displays sociodemographic, trauma, and baseline health characteristics of study participants. Groups were statistically similar across all characteristics. On average, participants scored above the cutoff for probable PTSD and had at least moderate levels of stress (≥4/10; Table 1). No participants in either group reported adverse events regarding study procedures.

Figure 1.

Figure 1.

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Participant flow through the randomized controlled trial.

Primary outcome measures

Table 2 displays group×time outcomes through 8-weeks for all variables. For the unadjusted analysis, there was a main effect for time with decreased PTSD, pain, and disability across both groups. After adjusting for baseline pain catastrophizing scores, there was a significant group×time interaction for PTSD scores (Table 2). Post-hoc testing revealed that the PNE group experienced a reduction in their PCL scores at 4-weeks of 12.1 (±12.6), p = .006. This reduction exceeded the MCID and was maintained at 8-weeks at 12.6 (±11.2) points lower than baseline (p = .001). The traditional group did not achieve a significant reduction in PTSD symptoms. Although the overall GLM ANOVA failed to find a significant group×time interaction for disability or pain (Table 2), the PNE group was more likely to achieve a clinically relevant reduction in disability at 4 and 8-weeks (Table 3).

Table 2.

Study outcome group by time effects.

Outcome Baseline 4-weeks 8-weeks P value, interaction η2 P value, interaction, Adjusted η2, Adjusted
PCL (0–80)a  
 PNE (SD) 33.9 (20.0) 23.5 (18.8) 22.7 (13.1) .13+ .07 .045* .11
 Traditional (SD) 35.9 (23.4) 33.3 (24.9) 31.9 (24.3)  
RMDQ (0–24)a  
 PNE (SD) 11.5 (5.7) 7.0 (4.4) 6.7 (5.4) .12+ .08 .06 .11
 Traditional (SD) 12.9 (4.7) 11.4 (5.1) 11.1 (6.4)  
Pain NPRS (0–10)a  
 Experimental (SD) 4.8 (1.4) 3.2 (1.7) 3.2 (1.3) .44+ .03 .21 .06
 Traditional (SD) 6.2 (1.7) 5.1 (2.4) 5.4 (2.8)  
Stress (0–10)a  
 PNE (SD) 6.5 (2.2) 5.7 (2.2) 5.6 (1.9) .12 .08 .06 .11
 Traditional (SD) 5.6 (3.4) 6.7 (2.2) 6.3 (2.9)  
PCS (0–52)a  
 PNE (SD) 19.8 (13.2) 10.1 (7.1) 12.2 (11.1) .13+ .07 N/A N/A
 Traditional (SD) 26.9 (12.0) 24.9 (11.7) 23.6 (12.8)  
SOPA (0–4)a  
SOPA: Control  
 PNE (SD) 1.8 (.45) 2.7 (.40)e 2.8 (.78)e .006*+ .19 .007* .21
 Traditional (SD) 1.6 (.72) 1.6 (.60) 1.5 (1.0)  
SOPA: Disability  
 PNE (SD) 2.1 (.73) 1.6 (.84) 1.9 (.89) .40 .03 .39 .04
 Traditional (SD) 2.5 (.70) 2.4 (.83) 2.5 (.93)  
SOPA: Harm  
 PNE (SD) 2.0 (.60) .94 (.63)d 1.1 (.69)d <.001*+ .29 <.001* .32
 Traditional (SD) 2.2 (.71) 2.0 (.75) 2.1 (.67)  
SOPA: Emotion  
 PNE (SD) 2.3 (.77) 2.0 (.92) 2.2 (.74) .76 .01 .37 .01
 Traditional (SD) 2.2 (1.0) 2.1 (.93) 2.1 (.93)  
SOPA: Medication  
 PNE (SD) 2.2 (.82) 1.8 (.89) 1.8 (.99) .06 .10 .002* .21
 Traditional (SD) 2.6 (1.0) 2.6 (.87) 2.7 (.77)  
SOPA: Solicitude  
 PNE (SD) 1.3 (1.2) 1.1 (.77) 1.1 (.90) .42 .03 .25 .05
 Traditional (SD) 1.0 (1.1) .98 (1.0) 1.2 (1.2)  
SOPA: Cure  
 PNE (SD) 1.5 (.54) 1.4 (.76) 1.4 (.70) .24 .05 .18 .06
 Traditional (SD) 1.8 (.82) 1.4 (1.0) 1.6 (.85)  
PSEQ (0–60)a  
 PNE (SD) 36.2 (9.4) 44.5 (9.3)d 44.2 (11.0)d .004* .18 .01* .16
 Traditional (SD) 33.8 (13.3) 29.6 (11.1) 31.3 (15.8)  
Mean PPT Low Backb, kPA  
 PNE (SD) 248.7 (161.1) 376.7 (146.9) – .039*+ .15 N/A N/A
 Traditional (SD) 257.9 (137.0) 272.4 (197.8) –  
Mean PPT Shoulderb, kPA  
 PNE (SD) 327.8 (232.5) 379.0 (188.4) – .11 .09 N/A N/A
 Traditional (SD) 284.2 (171.9) 262.2 (145.1) –  
Forward Bendb, cm from floorc  
 PNE (SD) 20.2 (15.0) 11.6 (11.2)   .15+ – N/A N/A
 Traditional (SD) 32.8 (12.2) 28.7 (15.5)  
Exercise Score
(0–30)b 		 
 PNE (SD) – 18.7 (4.6)   .03* d = .91 N/A N/A
 Traditional (SD) – 15.1 (3.4)  
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PCL: Post-traumatic stress disorder checklist; RMDQ: Roland Morris Disability Questionnaire; PCS: Pain catastrophizing scale; PNE: Pain Neuroscience Education; NPRS: Numeric pain rating scale; SOPA: Survey of Pain Attitudes; PSEQ: Pain self-efficacy questionnaire. PPT: Pain Pressure Threshold. SD: standard deviation.

*Denotes group by time significance at the level of α =.05.

+Denotes significant main effect for time at the level of α =.05.

aPNE n = 13, Traditional n = 17.

bPNE n = 14, Traditional n = 16.

cNote, a lower number indicates greater range of motion. Baseline values were significantly different between groups and therefore post-treatment effect size was not calculated.

dSignificant at the level of α < .05 after post-hoc Bonferroni correction for multiple comparisons.

Table 3.

Percentage of participants meeting Minimal Clinically Important Difference (MCID) for outcomes.

Outcome MCID PNE Traditional P value
PCL, 4-weeks Yes (%)
No (%)		 5 (38.5%)
8 (61.5%)		 3 (17.6%)
14 (82.4%)		 .24
PCL, 8-weeks Yes (%)
No (%)		 8 (57.1%)
6 (42.9%)		 3 (15.8%)
16 (84.2%)		 .024*
Disability, RMDQ
4-weeks		 Yes (%)
No (%)		 9 (64.3%)
5 (35.7%)		 4 (23.5%)
13 (76.5%)		 .033*
Disability, RMDQ
8-weeks		 Yes (%)
No (%)		 10 (76.9%)
3 (23.1%)		 5 (26.3%)
14 (73.7%)		 .01*
Pain, NPRS
4-weeks		 Yes (%)
No (%)		 9 (64.3%)
5 (35.7%)		 6 (35.3%)
11 (64.7%)		 .16
Pain, NPRS
8-weeks		 Yes (%)
No (%)		 5 (38.5%)
8 (61.5%)		 4 (21.1%)
15 (78.9%)		 .43
PSEQ, 4-weeks Yes (%)
No (%)		 9 (64.3%)
5 (35.7%)		 1 (5.9%)
16 (94.1%)		 .001*
PSEQ, 8-weeks Yes (%)
No (%)		 9 (69.2%)
4 (30.8%)		 4 (21.1%)
15 (78.9%)		 .01*
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MCID: Minimal clinically important difference. RMDQ: Roland Morris Disability Questionnaire. NPRS: Numeric pain rating scale (MCID = 2 for this study). PCL: Post-traumatic stress disorder checklist. PSEQ: Pain self-efficacy questionnaire. *Denotes significance at the level of α =.05.

Secondary outcomes

In the unadjusted analysis, there was a main effect for time for pain catastrophizing, attitudes about pain (control and harm sub-scales), PPTs at the low back, and the forward bend test. There was a significant group×time interaction for pain self-efficacy and attitudes about pain (control and harm sub-scales), indicating the PNE group had significantly greater improvements over time compared to the traditional group for a large effect size (Table 2). These relationships remained significant even after adjusting for baseline pain catastrophizing scores. In addition, after adjusting for pain catastrophizing, participants in the PNE group were less likely to believe they required medication to manage their pain compared to the traditional group (large effect size, p = .002). Participants in the PNE group were able to tolerate higher levels of pressure in their low back before rating the sensation as painful for a large effect size (Table 2). Because these data were not normally distributed, the results were not adjusted for pain catastrophizing. In addition, on average, participants in the PNE group selected and completed exercises at a more challenging level than the traditional group (Table 2, p = .03, large effect size). The analysis for exercise scores did not include any covariates. All other secondary analyses generally favored the PNE group although were not statistically significant (See, Table 2, p = .06-.37, η2 = .01-.11, adjusted, small to medium-large effect).

At the 12-month follow-up, participants in the PNE group utilized healthcare for LBP at a significantly lower rate than participants in the traditional group (Figure 2). As the healthcare utilization data were not normally distributed, the median annual cost for LBP-related healthcare expenditures was $2600 for the traditional group and $614 for the PNE group, reflecting an annual cost savings of 76.4% for the PNE group. Additionally, participants in the traditional group were more than twice as likely to receive an invasive procedure compared to the PNE group (40% of individuals in the traditional group obtained an invasive procedure following the intervention versus only 16.7% of participants in the PNE group). For example, four individuals in the traditional group received fluoroscopically guided spinal injections, three obtained magnetic resonance imaging of the spine, and one individual underwent spinal surgery. No participants in the PNE group received these specific invasive procedures. The difference between these rates, however, were not statistically significant (p = .16).

Figure 2.

Figure 2.

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Healthcare utilization at 12 Monthsa.

*Denotes between group significance at the level of α =.05. Mann Whitney U test.a Note: 2 participants in the experimental group and 1 participant in the control group only consented for 6-months of f/u data.

According to the post-program questionnaire (Supplement 4), participants in the PNE group reported greater satisfaction in understanding the relationship between pain and stress compared to the traditional group. Participants in the PNE group were also more satisfied with the explanations that PNE gave for why stress management strategies can help with pain and stress (Supplement 4). These data were also not normally distributed and therefore non-parametric tests were utilized.

Success of participant blinding

Participants in the traditional and PNE groups were equally likely to believe they were in the PNE group, indicating successful participant blinding (Supplement 4, p = .20).

Discussion

Participants in both groups achieved reductions in PTSD symptoms, disability, and pain. When considering baseline levels of pain catastrophizing, however, participants in the PNE group experienced a significant reduction in PTSD symptoms whereas the traditional group did not. This reduction in PTSD symptoms exceeded the level considered clinically meaningful. Although the group×time interaction did not quite obtain significance for disability symptoms, a significantly higher proportion of participants in the PNE group achieved the recommended minimal improvement of 30% reduction in disability (Ostelo et al., 2008) compared to the traditional group at 4 and 8-weeks. This study did not, however, demonstrate statistical evidence that PNE was superior to traditional education in reducing disability or pain according to the study’s primary analysis. Participants in the PNE group attained higher pain self-efficacy and control over their symptoms. The PNE group was less likely to believe that exercise is harmful and medication is required to manage their symptoms and completed more challenging exercises than participants receiving traditional stress and pain education. Participants in the PNE group were able to tolerate higher levels of pressure in their low back before rating the pressure as painful, perhaps reflecting reconceptualization of nervous system sensitivity. Finally, over 12-months following enrollment in this study, participants in the PNE group were much less likely to seek healthcare for LBP than participants in the traditional group.

To the best of the authors’ knowledge, this is the first study to demonstrate that PNE can reduce PTSD symptoms, which includes hypervigilance, avoidance, reexperiencing, and negative cognitions (American Psychiatric Association, 2013). Finding effective treatments for co-morbid pain and PTSD has been reported as challenging (Li et al., 2021; Otis et al., 2009). Co-morbid pain and PTSD might be due to a hypervigilant nervous system that becomes more sensitive to potential dangers (Miller, 2000; Scioli-Salter et al., 2015; Van Marle et al., 2009). PNE is recommended for patients with a hypersensitive nervous system (I. Diener et al., 2016), and the results from this study indicate that patients with PTSD symptoms might be a population that could particularly benefit from PNE to reduce hypervigilance and avoidance symptoms.

The findings from this study regarding PPTs provide some objective support for the role of PNE in reducing hypervigilance. Participants in the PNE group tolerated significantly higher levels of pressure in their low back before they rated the stimulus as painful. If participants in the PNE group were less vigilant to danger in their tissues, then it might take more force to activate the pain neuromatrix (Moseley, 2003b) after learning how the nervous system contributes to pain. Other studies demonstrate that PNE can improve PPT values in patients with spinal pain (Malfliet et al., 2018; Pardo et al., 2018).

Exercise is an effective therapy for both low back pain (Hayden et al., 2005) and PTSD (Stubbs et al., 2017); however, individuals may avoid exercise if painful and considered harmful (Dobscha et al., 2008). PNE challenges the belief that on-going, persistent pain is directly attributable to damaged tissues but rather a hypervigilant nervous system. If participants believe the message of PNE, they may feel that their tissues are safe to exercise, even in the presence of on-going pain. The results from this study indicate that participants in the PNE group did, in fact, change their beliefs about pain as indicated by the SOPA-Harm subscale. Participants in the PNE group were less likely to believe that pain was a sign of damage, and that exercise might be harmful after the intervention. Participants in the PNE group completed more challenging exercises than the traditional group, which may indicate individuals in the PNE group believed exercise was less dangerous compared to individuals in the traditional group.

In addition, since PNE emphasizes that tissues are safe to move, even in the presence of pain, PNE might reduce avoidance behaviors by increasing participant pain self-efficacy. Self-efficacy is one of the most transcendent constructs influencing health behavior change (Sheeran et al., 2016) and is an important mediator of disability (Lee et al., 2015). A previous study found that PNE alone, but not combined with a traditional exercise program, improved pain self-efficacy scores (C. G. Ryan et al., 2010). C. G. Ryan et al. (2010) reported that an exercise program delivered by therapists who hold biomedical beliefs may contradict lessons delivered by PNE by encouraging the patient to attend to pain and protect body tissues during exercise. Consistent with the current study, a non-randomized study also found that PNE plus usual care resulted in increased pain self-efficacy (Rondon-Ramos et al., 2020). Improving pain self-efficacy is important because, although PNE did not significantly decrease pain more than traditional education, individuals in the PNE group may have felt empowered to participate more in valued activities, despite the pain, which is a major goal for rehabilitation programs (Van Hooff et al., 2021).

Although pain did not differ between groups in this study, the results regarding the improved disability at short-term follow-up may be consistent with a systematic review and meta-analysis for PNE and CLBP (Wood & Hendrick, 2019). According to Wood and Hendrick (2019) and the results from this study regarding disability, more research is needed to reduce the uncertainty regarding long-term benefits of PNE for CLBP. Consistent with Louw et al. (2014), however, this study found decreased healthcare utilization at 12-months post-treatment. Decreasing healthcare related costs for patients with chronic pain is a major goal for research and clinical practice (Clewley et al., 2018; Rhon et al., 2019), particularly given that the U.S. spends almost $88 billion per year treating spinal pain (Dieleman et al., 2016).

Although interdisciplinary programs are effective (Nguyen et al., 2020) and may result in cost-savings over time (Rogerson et al., 2010), some healthcare settings resist implementation of interdisciplinary programs due to concerns of unsustainable costs (Rogerson et al., 2010). The feasibility of implementing PNE in physical therapy may also achieve cost-savings with fewer resources, although a direct comparison would need to be tested to support this assertion. The results from this study suggest that the changes in beliefs about the nature of pain after receiving PNE from physical therapists could result in long-term behavior changes and decreased costs. Future research could implement mediation analysis and clarify the relationship between beliefs about pain and healthcare utilization. The PNE group consumed 76.4% less cost in LBP-related healthcare expenditures for 12-months following study enrollment. These results are consistent with another trial which found that a single session of PNE decreased average healthcare utilization by 45% for individuals receiving lumbar spine surgery (Louw et al., 2014).

Individuals who are fearful about LBP and have low locus of control for their pain are more likely to seek healthcare for LBP (Beyera et al., 2019). From a biomedical perspective of pain, it makes sense that individuals who believe pain is a sign of damaged structures would continue to seek healthcare in order to fix tissues until pain has resolved (LAVAND’HOMME, 2015). Therefore, this study supports the construct that PNE decreases fears that pain signifies damage and increases locus of control and confidence that body tissues are safe, even in the presence of pain. This is a major finding that adds some confirmation that PNE could target maladaptive cognitions that contribute to increased healthcare utilization for chronic pain (Huysmans et al., 2020). Given the importance of promoting optimal healthcare utilization for LBP in order to limit exposure to harmful or low-value procedures (Clewley et al., 2018), the trend of fewer invasive procedures in the PNE group for this study is promising.

Strengths and limitations

A limitation in this study is that not all participants were formally diagnosed with PTSD. However, over 80% of participants in this study had experienced a previous trauma and the average baseline PTSD symptoms for participants was above the cutoff for possible PTSD (Bovin et al., 2016). It is not uncommon for individuals with CLBP to have PTSD symptomology, even without trauma (DeCarvalho, 2010) and this study indicates that individuals with CLBP may benefit from a PNE program that addresses post-traumatic stress regardless of a formal PTSD diagnosis. This, however, should be confirmed in future research. Relatedly, this study did not assess concurrent or subsequent utilization of mental health services during the study period. It is possible that these services contributed to the change in PTSD symptoms among participants. It is also possible that PNE might encourage mental health treatments by providing a neurobiological rationale for cognitive therapies. These conjectures, however, should be explored in future research. In addition, adjusting for participant’s previous healthcare utilization or other covariates could add clarity that the results from this study were due to treatment effects and not individual healthcare seeking variability. However, Veteran disability ratings – a key contributor to healthcare utilization in the VA system (Elhai et al., 2008) – were statistically similar between the two groups.

Future research could also determine the moderating effect of Veteran or PTSD diagnosis on the effectiveness of PNE. A larger study, particularly since this study fell short of its recruitment goal, might identify if specific sub-groups of participants might particularly benefit from PNE. For example, Service Members with PTSD are likely to have a greater hypervigilance to threat than those without PTSD (Koch et al., 2016). Since PNE aims to decrease hypervigilance to threat (Benedict et al., 2021), Service Members with PTSD and pain may benefit more from PNE than those without PTSD. Furthermore, it would be helpful to compare the effectiveness of PNE in Veterans compared to Active Duty Soldiers.

Following this study, moderating effects were tested for PTSD diagnosis, Veteran/Soldier, and group versus individual. These moderating effects were not statistically significant. It is possible, however, that a larger sample size could have revealed important differences among these patient populations which may have clinical implications. The results from this RCT may not generalize to civilian populations, although it would be interesting to determine if PNE can be similarly adapted to affect PTSD in different trauma settings.

The PI for this study developed the PNE materials (Benedict et al., 2021) and delivered the intervention to most of the participants in the experimental arm. Although every participant followed a standardized outline, presentation, and education booklet, this could have introduced bias that influenced participants. Future research should confirm the results of this study in a larger sample, particularly regarding PTSD symptoms. Future research should also recruit and analyze Active Duty Soldiers separately to increase participant homogeneity and determine greater clarity in the effectiveness of PNE in Soldiers. In addition, it may help to remove patho-anatomical education about the spine and purely include psychosocial education in the traditional group to determine if PNE’s effectiveness was due to its superiority over traditional stress education or due to the deleterious effects of education that focuses on tissues. Finally, it would also be helpful to have an exercise-only group to separate the effects of the education versus supervised exercise.

Despite these limitations, there are several strengths to this research. This study implemented a novel PNE curriculum aimed at addressing the intersecting lanes of pain, stress, and PTSD in military Service Members. The design of this RCT allows for a reasonable assumption that the effects of this intervention were specific to PNE since both groups participated in the exact same exercise program and received the same amount of time with education and even many of the same recommendations and messages regarding sleep, relaxation, breathing, and stress management. This is the first study that demonstrates PNE may improve not just symptoms related to disability and beliefs about pain, but also PTSD symptoms. Finally, the electronic health record for Soldiers and Veterans allowed a comprehensive summary of costs and procedures performed 12 months following enrollment into this study.

Conclusion

Although PNE was not more effective than traditional stress and pain education in improving pain consistent with this study’s primary analysis, a greater proportion of participants who received PNE were more likely to achieve clinically meaningful and statistically significant improvements in PTSD symptoms and disability at short-term follow-ups, especially when controlling for baseline levels of pain catastrophizing. Furthermore, PNE improved pain self-efficacy, beliefs about pain, and pain-pressure thresholds in the short-term. At 12-months, participants in the PNE group were significantly less likely to seek healthcare regarding LBP than the traditional group. These preliminary findings should be confirmed in a larger trial.

Acknowledgments

The authors would like to acknowledge John Kelly and Robin Embry for their contribution to this research study.

Funding Statement

This research was partially funded with pilot funding from the Endowment from University Professorship in Health Sciences, College of Health Sciences, University of Kentucky.

U.S. Army Discosure

The opinions or assertions contained herein are the private views of the author(s) and are not to be construed as official or reflecting the views of the Department of the Army or the Department of Defense. Any citations of commercial organizations and trade names in this report do not constitute an official Department of the Army endorsement or approval of the products or services of these organizations. The investigators have adhered to the policies for protection of human subjects as prescribed in DOD Instruction 3216.02 and the research was conducted in adherence with the provisions of 32 CFR Part 219.

Data available statement

Due to the nature of this research, participants of this study did not agree for their data to be shared publicly, so supporting data is not available.

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