Effectiveness of a pain neuroscience education programme on the physical activity of patients with chronic low back pain compared with a standard back school programme: protocol for a randomised controlled study (END-LC)

Background and rationale

Low back pain remains a significant challenge for researchers, clinicians and healthcare professionals worldwide. It is a challenge to understand and model multiple processes entangled in low back pain and more widely in the persistence of pain or symptoms, to improve primary care, rehabilitation and cognitive therapies.1–4 Despite theoretical advancements, innovative approaches and numerous clinical studies, low back pain remains a prevalent health concern with substantial associated costs.5 Recent epidemiological data underscore the gravity of chronic low back pain, indicating a 50% increase in its prevalence over the past two decades. It represents the sixth leading cause of disability in the world.6 7

Education and interdisciplinary rehabilitation are treatments that have shown evidence of efficacy.1 8 They are highlighted for people suffering from chronic low back pain in most international recommendations and international authors have recently emphasised their interest.9

First, education aims to change misconceptions that people with chronic low back pain may have due to prior beliefs, avoidant attitudes, or catastrophic thoughts that have become established over the course of the life history of chronicisation of pain.

Historically, the first education programme in this field was developed in Sweden under the name of back school.10 The basis of the education was the presentation of biomechanical aspects, such as the increase in interdiscal pressure during physical stress. The presentation of ergonomic posture aimed to help patients ‘protect’ their back and prevent future spinal pathologies. Subsequently, many variants developed in North American countries. For example, Penttinen and colleagues11 proposed 10 lessons to increase physical activity in daily life and to train participants in ergonomic work techniques. This education aligns well with the biomedical model, emphasising the biological or mechanistic nature of back pain: the pain emanates from a mechanical dysfunction that persists in the spine. Two literature reviews showed weak or conflicting evidence for the effectiveness of back school, from very heterogeneous studies.12 13 However, when the back school is based on a biopsychosocial model in addition to a rehabilitation programme, it is recommended in certain guidelines.14

Indeed, the changes in therapeutic approaches over the last few decades have been developed from the biopsychosocial model, integrating psychological aspects and social factors.15 As an extension of this paradigmatical change, other types of education have emerged, such as pain neuroscience education.16 This approach involves didactic learning of the physiological mechanisms of pain, understanding the influence of psychoaffective factors, and central neurological processes. In other words, patients with chronic low back pain are provided with an understanding of pain as arising from the dynamics of multiple processes rather than a single stable mechanism. Fundamentally, chronic pain is embodied and alters perceptual processes.17 18

Moseley and colleagues16 19 demonstrated that pain neuroscience education is more effective than traditional back school education based on anatomy and biomechanics.

Through this brief literature review, we observe that the two educational techniques (back school vs pain neuroscience education) differ in their fundamental approaches, one being biomedical and the other biopsychosocial. Debates on the conceptual approach to low back pain are still ongoing.20 21 Beyond these discussions, it is essential to understand which educational content has a positive and lasting influence on individuals with low back pain.

Second, rehabilitation is considered as an adjunctive treatment option that focuses on physical activity in order to fight against disability.1 In view of the importance of physical activity, in France, the message delivered by health insurance is: ‘good treatment is movement’ because some mechanisms (eg, fear avoidance) lead to a significant reduction in physical activity with deleterious consequences for the person with low back pain (in terms of social, professional, family repercussions, and the physiological consequences that this entails). In this line, a recent review showed that the level of physical activity was associated with the prevalence of chronic low back pain: people with a medium level of physical activity have a 10% lower risk of low back pain than people with a low level.22 Moreover, it is well established that physical well-being and physical exercise can protect against chronicity.23 In chronic low back pain, the number of steps is commonly used to quantify the level of physical activity.24 25

Furthermore, extensive literature reviews have consistently demonstrated the beneficial impact of education in the short term and medium term on pain perception, disability, catastrophising and enhancement of physical performance, particularly when integrated with a rehabilitation regimen focused on physical exercises.26 27 However, it is noteworthy that the assessment of participants’ physical activity level is predominantly reliant on self-reported questionnaires pertaining to disability, rather than direct measurement. Consequently, despite the recognised importance of physical activity, current literature fails to ascertain whether education in pain neuroscience or participation in back school alongside a rehabilitation programme influences individuals’ physical activity levels in the medium term to long term. Additionally, there is often an acknowledgement of the need for further investigation to assess effectiveness beyond the initial 6-month period.28

Thus, the ecological and direct measurement of physical activity in daily life is of relevant interest in the context of chronic low back pain in order to assess the effect of a rehabilitation programme and educational sessions and to measure changes in the dynamic of chronicisation.

Taken together, these results indicate that education is relevant for people with chronic low back pain. Additional investigations are necessary to measure the long-term effects on physical activity of these educations. Moreover, literature reviews show positive effects for both types of education although the efficacy of back school is more uncertain.12 29 This is the reason why we hypothesise that physical activity will be greater at 3 months and then 1 year after providing education in the neuroscience of pain than after participating in a back school combined with a rehabilitation programme. More specifically, we expect that the number of steps taken per day following neuroscience education will be greater than after attending back school.


The main objective of the study is to evaluate the effectiveness of pain neuroscience education on physical activity 3 months after the intervention compared with back school in patients with chronic low back pain attending a multidisciplinary rehabilitation programme. The main measure is the average number of steps taken by participants over a week at home. This variable is at the heart of our study because we believe that it is, on the one hand, a criterion for judging the functional benefit of an education programme, and on the other hand, an extension of recent work on chronic low back pain, a main criterion to measure behavioural changes essential to modifying the dynamics of chronicisation through physical activity.

The secondary objectives are grouped into three categories. The first concerns comparing the effectiveness of the two education programmes at 3 months and 1 year on other variables measuring physical activity, occupational performance, pain intensity, central sensitisation, psychological variables specific to chronic pain (catastrophising and kinesiophobia), and quality of life. The second involves comparing the changes in these variables over time between the two groups. The third involves exploratory analyses to determine the predictors of maintaining physical activity for each programme to identify the success factors of the programmes.

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