Application of a neurophysiology pain education program in patients with chronic low back pain

It´s a longitudinal randomized clinical trial with blind assessment and 3 months follow-up to assess the effect of a Neurophysiology Pain Education program in patients with Chronic Low Back Pain. Group 1: Experimental. This group received a Neurophysiology Pain Education (NPE) program and therapeutic exercises sessions, consisting in two sessions about pain concepts to understand his/her own pain situation, in small groups (4-6 patients) and of 30-50 minutes duration; and a Therapeutic Exercise program based on stabilization exercises, stretching and basic aerobic exercise. The frequency of the two NPE sessions was: The one initial session The second one a month after The information provided at the NPE sessions was: The main concepts of pain neurophysiology were explained to the participants using an appropriate language: - Acute Vs. Chronic pain characteristics - Purpose of acute pain - How acute pain is originated in the nervous system: nociceptors, ion channels, neurons, action potential, peripheral sensitization, synapses, synaptic space, inhibitory and excitatory substances, spinal cord, ascending and descending pathways, role of the brain, memory and perception of pain. - How pain becomes chronic: nervous system plasticity, modulation, modification, central sensitization, neuromatrix theory. - Maintaining factors for central sensitization: emotions, stress, illness perception, thoughts of pain and pain behavior The NPE sessions run for a physiotherapist with specific training in chronic pain and pain neurophysiology gave both PNE sessions to all subjects. The therapeutic exercise program included:: a) a brief description of the exercises performed; Motor control exercises included were: - Isolated contraction of the transversus abdominis in supine crook lying. Subjects were told that the aim of the exercise was to achieve 10 contractions of 10 seconds of duration each. For the participants to be able to achieve this they were instructed to place the fingers in the antero-superior iliac spine (ASIS) and slowly contract to try to pull them together. - Pelvic elevation with previous transversus abdominis contraction. The initial posture for this exercise was the same as before. Participants were instructed to do 10 repetitions keeping the pelvis up for 5 seconds (previous transversus abdominis contraction), and to descend in a controlled way. Progression of this exercise was to lift the foot 2 centimeters from the ground while keeping the pelvis up. As we said. These progressions where only done by those who performed the other exercises correctly. - Combined contraction of the transversus abdominis and multifidi in prone. The subjects were told that the aim of the exercise was to be able to achieve 10 contractions of 10 seconds of duration each. In this case they where also given the instructions of “ think of moving the pelvis forward without actually moving it”. For those who found it difficult they where asked to place the fingers in the postero-superior iliac spine (PSIS) and slowly contract to pull them together to feel the contraction of the multifidi muscles and then try to combine both. - Head and shoulder lift in prone on elbows, keeping the same contraction from the previous exercise they where instructed to lift and hold for 5 seconds, ten repetitions, and to control on the way down. These exercises where only performed by those who achieved the previous one correctly. - Postural correction in sitting: they where asked to correct their posture keeping their feet on the floor in line with the hips, sitting on the isquiatic tuberosity (which they had felt with their hands), their spine in neural position. Once they had learned this posture they had to learn to maintain it using simultaneous contraction of the transversus and multifidi. They where asked to do this as much as possible during their daily activities. - Piriformis stretch: in supine crook lying, placing the lateral side of the foot over the contralateral knee and pulling towards the chest with the hands. - Erector spine stretch: on their knees, sitting on their heels, flexing the trunk and stretching the arms forwards - 20-30 minute continuous walk at a plausible speed The number, frequency and duration of sessions: Two x 20 minutes sessions; The one initial session after NPE session The second one a month after NPE session The format and location of sessions were supervised group sessions at the study site. Both face-to-face sessions where done in the Clinic where the trial took place and were supervised by a physiotherapist. The twice a day home exercises where done by the patients at their homes with no supervision. Neither the Rating of Perceived Exertion Scale or any other were used because motor control exercises are low load exercises Home exercise compliance was confirmed by asking in the last assessment how often they had performed the exercises. Patients had to choose from 5 possible answers from “never” to “always as demanded”.