People challenged with chronic back pain have been given hope with a new treatment that focuses on retraining how the back and the brain communicate, a randomised controlled trial run by researchers at UNSW Sydney and Neuroscience Research Australia (NeuRA) and several other Australian and European universities has shown.
The study, funded by the Australian National Health and Medical Research Council (NHMRC), was described today in a paper published in the Journal of the American Medical Association. The study, carried out at NeuRA, divided 276 participants into two groups: one undertook a 12-week course of sensorimotor retraining and the other received a 12-week course of sham treatments designed to control for placebo effects, which are common in low back pain trials.
Professor James McAuley from UNSW's School of Health Sciences, and NeuRA said sensorimotor retraining alters how people think about their body in pain, how they process sensory information from their back and how they move their back during activities.
"What we observed in our trial was a clinically meaningful effect on pain intensity and a clinically meaningful effect on disability. People were happier, they reported their backs felt better and their quality of life was better. It also looks like these effects were sustained over the long term; twice as many people were completely recovered. Very few treatments for low back pain show long-term benefits, but participants in the trial reported improved quality of life one year later.”
The new treatment challenges traditional treatments for chronic back pain, such as drugs and treatments that focus on the back such as spinal manipulation, injections, surgery and spinal cord stimulators, by viewing long-standing back pain as a modifiable problem of the nervous system rather than a disc, bone or muscle problem.
"If you compare the results to studies looking at opioid treatment versus placebo, the difference for that is less than one point out of 10 in pain intensity, it’s only short term and there is little improvement in disability. We see similar results for studies comparing manual therapy to sham or exercise to sham," Prof. McAuley said.
"This is the first new treatment of its kind for back pain – which has been the number one cause of the Global Disability Burden for the last 30 years – that has been tested against placebo."
How it works
Prof. McAuley said the treatment is based on research that showed the nervous system of people suffering from chronic back pain behaves in a different way from people who have a recent injury to the lower back.
“People with back pain are often told their back is vulnerable and needs protecting. This changes how we filter and interpret information from our back and how we move our back. Over time, the back becomes less fit, and the way the back and brain communicate is disrupted in ways that seem to reinforce the notion that the back is vulnerable and needs protecting. The treatment we devised aims to break this self-sustaining cycle,” he said.
Professor Lorimer Moseley AO, Bradley Distinguished Professor at the University of South Australia said, “This treatment, which includes specially designed education modules and methods and sensorimotor retraining, aims to correct the dysfunction we now know is involved in most chronic back pain and that’s a disruption within the nervous system. The disruption results in two problems: a hypersensitive pain system and imprecise communication between the back and the brain.”
The treatment aims to achieve three goals. The first is to align patient understanding with the latest scientific understanding about what causes chronic back pain. The second is to normalise the way the back and the brain communicate with each other, and thirdly, to gradually retrain the body and the brain back to a normal protection setting and a resumption of usual activities.
Professor Ben Wand of Notre Dame University, the clinical director on the trial, emphasised that by using a program of sensorimotor training, patients can see that their brain and back are not communicating well, but can also experience an improvement in this communication. He said, “We think this gives them confidence to pursue an approach to recovery that trains both the body and the brain.”
Training the body and the brain
Traditional therapies concentrate on fixing something in your back, injecting a disc, loosening up the joints or strengthening the muscles. What makes sensorimotor retraining different, according to Prof. McAuley is that it looks at the whole system – what people think about their back, how the back and brain communicate, how the back is moved, as well as the fitness of the back.
The study authors say that more research is needed to replicate these results and to test the treatment in different settings and populations. They also want to test their approach in other chronic pain states that show similar disruption within the nervous system. They are optimistic about rolling out a training package to bring this new treatment to clinics and have enlisted partner organisations to start that process.
Once the new treatment is available via trained physiotherapists, exercise physiologists and other clinicians – Prof. McAuley hopes this to occur in the next six to nine months – people with chronic back pain should be able to access it at a similar cost to other therapies offered by those practitioners.
Journal of the American Medical Association
Method of Research
Randomized controlled/clinical trial
Subject of Research
Effect of Graded Sensorimotor Retraining on Pain Intensity in Patients With Chronic LowBack Pain
Article Publication Date
Dr Bagg reported receiving grants from the Australian National Health and Medical Research Council (ID1087045), the Australian government (Australian Research Training Program Scholarship), the University of New SouthWales (UNSW Research Excellence Award), and Neuroscience Research Australia (PhD supplementary scholarship) and nonfinancial support from Neuro Orthopaedic Institute (Noigroup) (gratis attendance at 2 Explain Pain courses in 2015; gratis access to Explain Pain, Explain Pain Protectometer, and Recognise materials) during the conduct of the study and personal fees from Chiropractor’s Association of Australia (conference travel, webinars), Memorial University of Newfoundland (conference travel), and Active Linc Pty Ltd (workshop) outside the submitted work. DrWand reported receiving personal fees from Manual Concepts outside the submitted work. Dr Stanton reported receiving grants from National Health & Medical Research Council of Australia during the conduct of the study; grants from Arthritis Australia, Arthritis SA, Australia Pain Society/Australia Pain Relief Association/Cops for Kids, and National Health & Medical Research Council of Australia outside the submitted work; and royalties for books on pain education and rehabilitation from NOIgroup publications and has received payment for lectures provided on pain and rehabilitation. Dr O’Connell reported receiving grants from the National Institute for Health and Care Research (UK), the Alzheimer’s Society, and the Campbell Collaboration/Youth Endowment Fund and has received speakers fees for lectures provided on evidence in pain from the San Diego Pain Summit. Dr O’Hagan reported receiving grants from Australian Commonwealth Government Research Training Program and Neuroscience Research Australia during the conduct of the study.Mr Rizzo reported receiving research tuition fees from the University of New SouthWales and PhD supplementary scholarship from Neuroscience Research Australia during the conduct of the study. MrWewege reported receiving grants from National Health and Medical Research Council Postgraduate Scholarship, University of New SouthWales School of Medical Sciences Top-Up Scholarship, and Neuroscience Research Australia (PhD supplementary scholarship) during the conduct of the study. Dr Rabey reported Research Original Investigation Effect of Graded Sensorimotor Retraining on Pain Intensity in Patients With Chronic Low Back Pain 438 JAMA August 2, 2022 Volume 328, Number 5 (Reprinted) jama.com Confidential: Embargoed Until 11:00 am ET, August 02, 2022. Do Not Distribute © 2022 American Medical Association. All rights reserved. receiving grants from Neuroscience Research Australia during the conduct of the study. Dr Goodall reported receiving grants from the government during the conduct of the study. Dr Maher reported receiving grants from National Health and Medical Research Council during the conduct of the study and nonfinancial support from Flexeze, which provided heat wraps at no cost for the SHaPED trial outside the submitted work. Dr Moseley reported receiving grants from National Health and Medical Research Council of Australia General (salary support) during the conduct of the study and royalties for books on pain education and rehabilitation from NOIgroup publications and royalties for books on pain education and rehabilitation from OPTP, nonfinancial support from Reality Health for expense reimbursement for advice on pain education and rehabilitation, personal fees from ConnectHealth for UK medical advisory group membership, and being director of Pain Australia outside the submitted work; and receiving speaker or consultancy fees or reimbursement for travel and conference registration from professional societies, the international Olympic committee, professional sporting clubs and organizations, government and industry in the fields of pain education, physiotherapy, and rehabilitation. Dr McAuley reported receiving grants from the National Health and Medical Research Council of Australia (grant number 1087045 [from 2015-2020]) and receiving intervention books and online materials total of approximately AUD $3000 value from Neuro-Orthopaedic Institute of Australia during the conduct of the study. No other disclosures were reported.