Pain biology education and exercise classes compared to pain biology education alone for individuals with chronic low back pain: A pilot randomised controlled trial

Abstract

The aim of this single-blind pilot RCT was to investigate the effect of pain biology education and group exercise classes compared to pain biology education alone for individuals with chronic low back pain (CLBP). Participants with CLBP were randomised to a pain biology education and group exercise classes group (EDEX) [n = 20] or a pain biology education only group (ED) [n = 18]. The primary outcome was pain (0–100 numerical rating scale), and self-reported function assessed using the Roland Morris Disability Questionnaire, measured at pre-intervention, post-intervention and three month follow up. Secondary outcome measures were pain self-efficacy, pain related fear, physical performance testing and free-living activity monitoring. Using a linear mixed model analysis, there was a statistically significant interaction effect between time and intervention for both pain (F[2,49] = 3.975, p < 0.05) and pain self-efficacy (F[2,51] = 4.011, p < 0.05) with more favourable results for the ED group. The effects levelled off at the three month follow up point. In the short term, pain biology education alone was more effective for pain and pain self-efficacy than a combination of pain biology education and group exercise classes. This pilot study highlights the need to investigate the combined effects of different interventions.

Introduction

Chronic low back pain (CLBP) is a complex condition for which many different interventions exists. A number of different treatments have been shown to be effective including; education, exercise, manual therapy, multidisciplinary and cognitive behavioural interventions (Hilde and Bo, 1998, Abenhaim et al., 2000, Tugwell, 2001, Guzman et al., 2002, Moffett and Mannion, 2005, Waddell and Burton, 2005, Airaksinen et al., 2006). Clinical management of patients with CLBP often comprises of two or more different management strategies delivered simultaneously. This can occur without evidence that the two management strategies have a synergistic effect. The interaction effects of different management strategies need to be further investigated so that appropriate combinations of interventions can be delivered for each patient.

Group, aerobic based, exercise classes are a common management strategy for individuals with CLBP. A number of randomised controlled trials have found such classes to be beneficial for this patient group (Frost et al., 1995, Frost et al., 1998, Moffett et al., 1999, Klaber Moffett et al., 2004, UK BEAM Trial Team, 2004). The exact mechanisms by which group exercise classes bring about a therapeutic effect are not fully understood. It may be that psychosocial, rather than physical, mechanisms bring about the effect considering that as few as four to five classes can bring about a therapeutic effect despite this being an insufficient training stimulus to bring about physiological training effects (Klaber Moffett et al., 2004).

Pain biology education is a relatively new intervention for the management of CLBP. It is a cognitive behavioural based intervention which attempts to reduce pain and disability by explaining the biology of the pain to the patient (Butler and Moseley, 2003). This type of education has been shown to be superior to more biomedical forms of education for this patient group (Moseley et al., 2004). Pain biology education has also been found to be useful when delivered in combination with usual care physiotherapy (Moseley, 2002).

Considering both pain biology education and group exercise classes attempt to decrease fear of harm and increase physical activity (PA) in a paced manner it is logical to suggest that both interventions delivered together would have an added benefit to one another. However, the combined effect of these interventions has not been investigated. Such work is required to guide clinical practise.

The aim of this study was to provide pilot data investigating the combined effect of pain biology education and group exercise classes compared to pain biology education alone for individuals with CLBP. The primary outcome measures were self-reported pain and function. Secondary outcome measures were pain related fear, pain self-efficacy, physical performance testing and free-living physical activity (PA) monitoring.