Pain neuroscience education for patients undergoing lumbar surgery?   November 26th, 2016

​On October 3rd 2016 a (Dutch) blog post was published on our website concerning a study comparing ‘back school’ and ‘brain school’ in patients undergoing surgery for lumbar radiculopathy, titled “Rugschool of pijneducatie bij chirurgie voor lage rug- en beenpijn”. This research project is based on the results of a proof of concept randomized controlled trial by Adrian Louw et al., being the subject of this blog post.

Research has shown that, in general, patients are satisfied with the care provided preoperatively, but not with the information provided regarding their lumbar surgery (Louw et al. 2009; Ronnberg et al. 2007). Therefore implementing an educational program preoperatively might be useful.

However, the question remains which content the session should contain. Louw et al. 2009 found in a previous study that patients wanted more education regarding their pain and the impact of surgery on it. Based on this and other previous research, Louw et al. 2014 chose to investigate the effect of a single preoperative pain neuroscience education session on several outcomes.

The educational session of the intervention group dealt with physiology of the nervous system and nerve sensitization, as well as calming the nervous system and recovery after lumbar surgery. Patients in the control group only received “usual care”.

Once a patient was enrolled in the study he/she underwent baseline assessments and received an educational session on pain neurosciences or usual care. Patients were further followed up at 4 time points: 1, 3, 6 and 12 months post-surgery. The investigated outcome measures were pain, functioning (Oswestry Disability Index), postoperative thoughts and beliefs about the surgery and postoperative health care utilization.

This study found no significant difference on low back and leg pain intensity, neither on functioning between the group receiving pain neuroscience education and the control group, although there was a non-significant positive trend 1-month postoperatively in favour of pain neuroscience education. In contrast, positive effects were found on the postoperative thoughts and beliefs of the patients, and on costs related to health care utilization after lumbar surgery, which were significantly lower in the intervention group.              

Possibly, these results indicate that the degree of reconceptualization of pain, which is the main focus of pain neuroscience education, was not enough using only a preoperative session to affect the primary pain-focused outcome measures. However, the effect of this treatment session is already reflected in the behaviour of patients, as they apparently experienced a decreased need to seek for help. These, though secondary outcomes, are off course of great importance for society.

Therefore it might be needed to investigate this intervention more in depth and extend the intervention with a postoperative session, to possibly establish also significant improvements in pain related outcomes. That is where the B²aSic trial, which was already described in brief in the Dutch blog post mentioned before, comes in the picture.

This trial, which is currently performed by Pain in Motion members and other researchers in different fields, aims at comparing perioperative pain neuroscience education and conventional back school in patients undergoing surgery for lumbar radiculopathy. All patients receive an equal amount of therapy, with both therapies consisting of an educational session with different contents in both groups. Hence, the educational session is extended compared to the proof of concept trial by Louw et al. 2014, comprising now a pre- and postoperative session, supplemented by an educational leaflet. Also, the follow-up was prolonged until 24 months postoperatively. The investigated outcome measures are: intensity of pain, conditioned pain modulation, brain activity by EEG monitoring during painful electrical stimulation,  return to work, health care utilisation and related costs, and psychosocial outcomes (kinesiophobia, pain catastrophizing and pain vigilance and awareness).

Have your say:

“Do you think perioperative pain neuroscience education might be a good treatment option in patients undergoing surgery for lumbar radiculopathy?”

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Eva Huysmans

2016  Pain in Motion

References and further reading:

Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative Pain Neuroscience Education for Lumbar Radiculopathy: A Multicenter Randomized Controlled Trial With 1-Year Follow-up. Spine (Phila Pa 1976) 2014; 39(18): 1449-57.

Louw A , Louw Q , Crous LCC . Preoperative education for lumbar surgery for radiculopathy . S Afr J Physiother 2009 ; 65 : 3 – 8 .

Ronnberg K , Lind B , Zoega B , et al. Patients’ satisfaction with provided care/information and expectations on clinical outcome after lumbar disc herniation surgery . Spine 2007 ; 32 : 256 – 61 .

Ickmans K, Moens M, Putman K, et al. Back school or brain school for patients undergoing surgery for lumbar radiculopathy? Protocol for a randomised, controlled trial. J Physiotherapy 2016; 62(3):165.