ORIGINAL ARTICLE

Comparing Pain Neuroscience Education

Followed by Motor Control Exercises With
Group-Based Exercises for Chronic Low Back
Pain: A Randomized Controlled Trial

Pouya Rabiei , MSc*; Bahram Sheikhi, MSc†; Amir Letafatkar , PhD†

*Department of Physical Education and Sports Sciences, Karaj Branch, Islamic Azad University,
Karaj,; †Sports Injury and Corrective Exercises, Faculty of Physical Education and Sports
Sciences, Kharazmi University, Tehran, Iran

& Abstract intervention. A 2 9 2 variance analysis (treatment

group 9 time) with a mixed-model design was applied to
Background: Different individualized interventions have
statistically analyze the data.
been used to improve chronic low back pain (CLBP). However,
Results: Both groups showed significant improvements in
their superiority over group-based interventions has yet to be
all the outcome measures, with a large effect size (P < 0.001,
elucidated. We compared an individualized treatment involv-
partial eta squared [gp2] = 0.66 to 0.81) after the interven-
ing pain neuroscience education (PNE) plus motor control
tion. The PNE plus MCE group showed greater improvements,
exercise (MCE) with group-based exercise (GE) in patients
with a moderate effect size in pain intensity (P = 0.041,
with CLBP.
gp2 = 0.06) and disability (P = 0.021, gp2 = 0.07) compared
Methods: Seventy-three patients with CLBP were randomly
to the GE group. No significant difference was found in fear-
assigned into the PNE plus MCE group (n = 37) and GE group
avoidance beliefs during physical activity and work, and self-
(n = 36). Both PNE plus MCE and GE were administered twice
efficacy (P > 0.05) between the 2 groups.
weekly for 8 weeks. Pain intensity (as measured using the
Conclusion: PNE and MCE seem to be better at reducing
VAS), disability (as measured using the Roland-Morris Dis-
pain intensity and disability compared to GE, while no
ability Questionnaire), fear-avoidance beliefs (as measured
significant differences were observed for fear-avoidance
using the Fear-Avoidance Beliefs Questionnaire), and self-
beliefs and self-efficacy between the 2 groups in patients
efficacy (as measured using the Pain Self-Efficacy Question-
with CLBP. With regard to the superiority of individualized
naire) were assessed at baseline and 8 weeks post-
interventions over group-based ones, more studies are
warranted. &

Address correspondence and reprint requests to: Pouya Rabiei, MSc, Key Words: disability, fear, low back pain, pain neuro-
Department of Physical Education and Sports Sciences, Karaj Branch,
science education, therapeutic intervention
Islamic Azad University, Moazen Street, Karaj, Iran. E-mail: pouya.
rabiei.pr@gmail.com.
Trial registration: Registered at UMIN-CTR website, and the unique
trail number is: UMIN000033767. INTRODUCTION
Submitted: May 13, 2020; Revised October 24, 2020;
Revision accepted: October 26, 2020 Chronic low back pain (CLBP) has been considered as
DOI. 10.1111/papr.12963
one of the most prevalent health conditions, which
significantly contributes to disease burden worldwide,
© 2020 World Institute of Pain, 1530-7085/20/$15.00 but it has been poorly studied and explained. To treat
Pain Practice, Volume 21, Issue 3, 2021 333–342
334  RABIEI ET AL.

such a disabling condition, several nonsurgical treat- hypothesized that patients receiving individualized PNE
ments, including joint manipulation, acupuncture, gen- plus MCE would demonstrate better improvement in
eral therapeutic exercises, and pharmacologic pain intensity and disability as well as psychologically
therapy,1,2 have been introduced. However, effect sizes based outcomes (fear-avoidance beliefs and self-efficacy)
(ES) of these treatments are usually small, thus suggest- compared to those receiving GE.
ing that effective structured treatment strategies are
required to achieve the desired treatment effect.
Indeed, the existing different strategies seem inade- METHODS
quate in the treatment of CLBP since they have neglected
Study Design
pain cognition, behavioral aspects, and the knowledge
in pain physiology.3 In addition, evidence related to This was an assessor-blind, 2-arm RCT conducted
impaired spinal motor control in patients with CLBP is between May 2017 and July 2019 and prospectively
accumulating.1,2,4,5 Impaired motor control in patients registered at www.umin.ac.jp (with trial number:
with CLBP indicates that the spinal muscles are no UMIN000033767). The study was approved by the
longer able to accurately control body postures and Institutional Review Board at Kharazmi University.
movements.1,2 Thus, an intervention to address both Before enrollment, all eligible patients were asked to
pain cognition and optimal function of the back muscles sign an informed consent form based on the ethical
to improve motor control of the spine might likely result standards of the Helsinki Declaration.
in larger ES.
A treatment strategy involving pain neuroscience
Participants and Flow
education (PNE) followed by cognition-targeted motor
control exercises (MCE) has been introduced.6,7 This Patients were recruited only by physical therapists via
treatment approach focuses on educating patients on the flyers displayed at physical therapy clinics to receive
mechanism behind chronic pain (central pain and physiotherapy treatment. Of 110 patients enrolled for
central sensitization and the cognitive-affective mecha- the study, 80 met the inclusion criteria.
nisms of pain) followed by individualized motor control/ The inclusion criteria were as follows: (1) Persian-
functional exercises, which may help patients progres- native men and women between 30 and 60 years of age,
sively return to those activities about which the patients and (2) primary complaint of low back pain
are fearful and doubt that they can perform.8 In this (>3 months’ duration, typically located between the
regard, a previous randomized controlled trial (RCT)7 lower rib margins and the buttock creases with no
found that a program of PNE combined with cognition- specific and determined pathoanatomical cause) diag-
targeted motor control training resulted in significant nosed by an experienced physical therapist. The exclu-
improvement in pain intensity, disability, and function sion criteria were as follows: (1) previous spinal surgery
compared to a best-evidence physiotherapy intervention and neurological signs, (2) specific spinal pathology
in patients suffering from chronic spinal pain. (tumor, infection, fracture, inflammatory disease), (3)
In addition, a recent systematic review and meta- serious pathology or health condition that could prevent
analysis found that group-based exercise (GE) programs patients from performing an exercise program, and (4)
resulted in effects clinically similar to those observed in patients receiving any intervention deemed contradic-
individualized physiotherapy programs.9 However, this tory to some exercises (eg, manual therapy, ultrasound,
review considered the inclusion of different muscu- or shortwave therapy) during the trial period. Prior to
loskeletal conditions, not specifically LBP, and various randomization, socio-demographic data and baseline
types of individualized physiotherapy such as manual clinical outcome variables of all the participants were
therapy, education, and relaxation.9 Given the lower collected and recorded by a blinded assessor.
healthcare costs of GE, using GE was concluded to be
more preferable in clinical practice.9
Randomization
Considering the limited evidence regarding the com-
parative effectiveness of individualized and group-based Patients were randomly assigned into 1 of 2 treatment
interventions, this RCT was conducted to determine if groups at a ratio of 1:1 as follows: PNE plus MCE group
individualized treatment involving PNE plus MCE (n = 40) or GE group (n = 40). The randomization was
would be superior to GE in patients with CLBP. We performed by an independent person who was not
 Pain Education and Exercise for Low Back Pain  335

involved in other procedural aspects of the study. movement patterns while recruiting both the deep and
Randomization was achieved by drawing a number superficial spinal muscles, similar to the functional
(from 1 to 80) prepared in advance and placed in sealed tasks, first using static, and then applying dynamic
opaque envelopes in a box. tasks. The related exercises were aimed to improve the
coordination, posture, and stability of the spine. During
the exercise sessions, posture, movement, and breathing
Interventions
patterns were assessed, and related performance was
Pain Neuroscience Education. Patients in the PNE corrected.11 In order to maximize transfer to daily
plus MCE group took part in 3 PNE sessions situations, progression involved both exercise during
conducted by a licensed physical therapist (Persian physically demanding tasks and exposure to the feared
native speaker) who was well trained in the PNE and movements or activities, and exercise during psychoso-
MCE program. Each PNE session lasted between 30 cially stressful conditions.
and 60 minutes for each patient. The PNE was aimed
to reconceptualize the patients’ negative beliefs about Group-Based Exercise. Patients allocated to the GE
the pain. These beliefs might have been imposed by group performed low back–strengthening exercises for
potentially unhelpful diagnostic, prognostic, or thera- 16 sessions (twice a week for 8 weeks). The exercises were
peutic conclusions made in the patients’ minds.7,10 conducted in group sessions and under the supervision of
During the PNE sessions, information about the nature a well-experienced physical therapist (who was not
of pain was also targeted to reduce fear-avoidance involved in the treatment of the other group). The session
beliefs and avoidance behavior, and consequently to included 10 persons and was conducted for 60 minutes;
promote self-efficacy. Key messages were delivered in specifically, the session was composed of a 10-minute
this stage using verbal instructions, diagrams, and free- group-based warm-up, a 45-minute span of strengthen-
hand drawings.7,10 ing exercises for the trunk and upper and lower limbs,
and finally a 5-minute cool-down with light exercises.
Motor Control Exercise. The MCE program provided The exercises performed included trunk extension in a
in this study was identical to that described by Macedo supine position (bridge), trunk extension in a prone
et al.11 Sixteen sessions of MCE (twice a week) were position (cobra), hip extension in a prone position, and
provided to the patients for 8 weeks. In the first session, alternating superman, curl-up, and bird dog exercises.
the patients were individually examined by the physical The exercises were performed in 3 sets with 10 repeti-
therapist (who had delivered the PNE), and prescribed tions, with a 1-minute rest between each set and a 3-
exercises were based on the patients’ tolerance/ability. minute rest between each exercise. All patients per-
The intended exercises were designed in 2 parts, with formed repetitions and rest time together. Based on the
specific criteria met by each patient. Both parts of the tolerance of each patient, exercise intensity (holding time
exercises were performed individually under the super- and number of repetitions) was gradually increased.12
vision of the physical therapist.
The training consisted of sensorimotor control train- Outcome Measures
ing by facilitating the proprioceptive system and opti-
mizing the coordinative muscle recruitment patterns. The primary outcomes were pain intensity and disabil-
The patients were instructed to contract their deep ity, whereas the secondary outcomes were fear-avoid-
spinal muscles (eg, transversus abdominis, multifidus) ance beliefs during work and physical activity, and self-
separate from the superficial ones. In this regard, the efficacy. All outcomes were assessed pre-test and post-
exercises were progressed and enriched by adding test by a blinded assessor.
diaphragm and pelvic floor muscle exercises. Progres-
sion was ensured until each subject was able to maintain Pain Intensity. Pain intensity was rated by the patients
isolated contractions of the target muscles for 10-second using the VAS (scale of 0 to 10) for pain, with 0
repetitions.11 When this level of competence was signifying no pain and 10 signifying the worst imagin-
achieved, the patients were deemed ready to progress able pain. The patients were asked to rate their current
to the next part. level of pain. The VAS is a valid and reliable tool for
In the second part, additional loads were placed on evaluating self-reported pain (intraclass correlation
the spine by performing various extremity and trunk coefficient [ICC] = 0.91).13
336  RABIEI ET AL.

Disability. The Persian version of the Roland-Morris on the research procedures, data were presented as
Disability Questionnaire (RMDQ)14 was used to assess mean  standard deviation (SD). A 2 9 2 variance
disability. It has been shown to be a valid and reliable analysis (treatment group 9 time) was conducted with a
tool (ICC = 0.83) for assessing physical disability mixed-model analysis design. For each variable, the
caused by LBP.14 The RMDQ is a 24-item patient- percentage of change was calculated compared with
reported outcome measure that inquires about pain- baseline. ES using partial eta squared (gp2) was calcu-
related disability resulting from LBP. Items are scored 0 lated to provide a measure of clinical meaningfulness. ES
if left blank or 1 if endorsed, for a total RMDQ score were considered as small (0.01), moderate (0.06), and
ranging from 0 to 24; higher scores represent higher large (0.14) based on the study of Cohen (1992).18 All
levels of pain-related disability. data analyses were conducted using SPSS version 26
software (IBM Corp., Armonk, NY, U.S.A.) at an alpha
Fear-Avoidance Beliefs. The Persian version of the level of 0.05.
Fear-Avoidance Beliefs Questionnaire (FABQ)15 was
used to assess fear-avoidance beliefs during physical
RESULTS
activity and work. It includes 16 items related to
physical activity (FABQ-PA) and work (FABQ-W) The 2 groups were comparable at baseline as there was no
affecting the patient’s LBP. With regard to the FABQ- significant difference (P > 0.05) in the demographic and
W, those with scores > 34 (out of a possible 42 points) clinical variables between the groups (Table 1). Seven
have been shown to be less likely to return to work by patients were lost to follow-up due to personal reasons
4 weeks; for the FABQ-PA, those with a score of 15 (out (PNE plus MCE group, n = 3; GE group, n = 4), yielding
of a possible 24 points) have revealed fear-avoidance a retention rate of 91% (73 out of 80; Figure 1). No
beliefs related to physical activities.15 The Persian undesirable or adverse event was reported.
version of the FABQ has been reported to be a valid
and reliable measure (ICC = 0.80) of fear-avoidance
Treatment Effects
beliefs in patients with LBP.15
There was a significant main effect for time with large
Self-Efficacy. The Persian version of the Pain Self- effect size, with both groups showing decreases in VAS
Efficacy Questionnaire (PSEQ)16 was used to assess self- (F[1, 73] = 140.73, P < 0.001, and gp2 = 0.665),
efficacy. The questionnaire has been found to be a valid RMDQ (F[1, 73) = 320.29, P < 0.001, and
and reliable measure (ICC = 0.92) of pain self-efficacy gp2 = 0.819), FABQ-W (F[1, 73) = 201.02,
beliefs.16 The PSEQ is a 10-item questionnaire with P < 0.001, and gp2 = 0.739), and FABQ-PA scores (F
possible scores ranging from 0 to 60 to assess patients’ [1, 73] = 245.42, P < 0.001, and gp2 = 0.776), and
confidence about their ability in performing a range of increases in PSEQ scores (F[1, 73] = 136.45, P < 0.001,
activities despite pain. For example: “I can do most of and gp2 = 0.658) across the time periods (Table 2).
the household chores (eg, tidying up, washing dishes), Similarly, a significant interaction between group and
despite the pain” and “I can gradually increase my time (P < 0.001 and P < 0.05) was found for all
activity level, despite the pain.” Lower scores for the
PSEQ indicate lower levels of confidence.
Table 1. Demographic Data and Baseline Values of
Patients With Chronic Low Back Pain
Sample Size Calculation and Statistical Analysis Characteristic PNE Plus MCE Group GE Group P Value

Sample size calculations using G*Power software as in Age (years) 42.46  9.7 44.19  8.79 0.43
Body weight, kg 76.44  8.29 74.05  8.86 0.24
the previous studies9,12,17 resulted in a sample of 66 Body height, m 1.68  0.10 1.67  0.07 0.67
patients (33 patients per group). Considering a 20% BMI, kg/m2 27.15  4.36 26.47  4.09 0.50
Female, n (%) 21 (56.75) 18 (50) 0.40
attrition rate, an effect size of 0.25, a statistical power of Smoker, n (%) 12 (32.43) 9 (25) 0.49
0.8%, and an alpha of 0.05 (2-tailed test), a total sample Low back pain duration n (%)
3 to 12 months 8 (22) 13 (36) 0.41
size of 80 was required (40 patients per group).
13 to 36 months 10 (27) 8 (22) 0.64
The Kolmogorov-Smirnov test and Levene’s test were >36 months 19 (51) 15 (42) 0.18
conducted to assess the normality of the dependent BMI, body mass index; GE, group-based exercise; PNE plus MCE, pain neuroscience
variables, and all the variables showed P > 0.05. Based education followed by motor control exercise.
 Pain Education and Exercise for Low Back Pain  337

Figure 1. Consolidated Standards of Reporting Trials (CONSORT) flow diagram of the study. GE, group-based exercise; MCE, motor
control exercise; PNE, pain neuroscience education.

outcomes except for the RMDQ score (P > 0.05; see gp2 = 0.073; see Table 2) in the PNE plus MCE group
Table 2). This indicates that the changes in these demonstrated superior improvements compared to
outcome scores were not equal between the 2 groups those in the GE group (VAS score: mean difference
after the intervention. Following up on this interaction 0.51, 95% confidence interval [CI] 1.00 to 0.22;
showed that there was no significant difference between RMDQ score: mean difference 1.02, 95% CI 1.88
the groups at baseline. However, the mean VAS, FABQ- to 0.15; Figure 2). For the secondary outcomes, no
W, FABQ-PA, and PSEQ scores of the groups improved significant main effect comparing the 2 groups was
after intervention, more so for the PNE plus MCE group. found (P > 0.05; Table 2, Figure 3).
For the main effect comparing the 2 groups, a
statistically significant difference with moderate effect
DISCUSSION
size was found for the primary outcomes: VAS score (F
[1, 73] = 4.334, P = 0.041, and gp2 = 0.058) and This study investigated the effect of an individualized
RMDQ score (F[1, 73] = 5.562, P = 0.021, and treatment involving PNE followed by MCE compared to
338  RABIEI ET AL.

Table 2. Mixed Between-Within Subjects Analysis of Variance for the Primary and Secondary Outcomes Assessed in
the Study

Interaction Effect Between-Subjects

Within-Subjects Effect (Group 9 Time) Effect
Baseline 8 weeks D Relative to
Outcomes Group Mean  SD Mean  SD Baseline (%) F P gp2 F P gp2 F P gp2

VAS PNE plus 6.45  1.21 3.79  1.02 ↓ 41.2 140.73 <0.001 0.665 12.45 0.001 0.149 4.334 0.041 0.058
MCE
GE 6.36  1.14 4.91  1.67 ↓ 22.8
RMDQ PNE plus 14.6  1.55 7.94  2.17 ↓ 45.6 320.29 <0.001 0.819 2.429 0.124 0.033 5.562 0.021 0.073
MCE
GE 15.0  2.14 9.50  3.25 ↓ 37.0
FABW-W PNE plus 24.2  10.4 11.5  6.41 ↓ 52.4 201.02 <0.001 0.739 18.58 <0.001 0.207 0.052 0.819 0.001
MCE
GE 21.6  8.02 14.9  6.43 ↓ 31.2
FABW-PA PNE plus 17.2  4.25 8.24  3.72 ↓ 51.9 245.42 <0.001 0.776 13.52 <0.001 0.160 0.063 0.803 0.001
MCE
GE 15.7  5.17 10.2  4.15 ↓ 35.2
PSEQ PNE plus 26.6  9.53 43.9  11.6 ↑ 65.3 136.45 <0.001 0.658 11.66 0.001 0.141 0.194 0.661 0.003
MCE
GE 29.5  10.9 38.9  12.0 ↑ 32.2

GE, group-based exercise; PNE plus MCE, pain neuroscience education followed by motor control exercise; D, percent change (↓ decrease, ↑ increase); gp2, partial eta squared (effect
size).
VAS: scores range from 0 (“no pain”) to 10 (“high pain”); RMDQ, Roland-Morris Disability Questionnaire: scores range from 0 (“no pain-related disability”) to 24 (“high pain-related
disability”); FABQ-W, Fear-Avoidance Beliefs (work) Questionnaire: scores range from 0 (“no fear”) to 42 (“high fear”); FABQ-PA, Fear-Avoidance Beliefs (physical activity)
Questionnaire: scores range from 0 (“no fear”) to 24 (“high fear”); PSEQ, Pain Self-Efficacy Questionnaire: scores range from 0 (“no confidence”) to 60 (“high confidence”).

Figure 2. Pain intensity (VAS): scores range from 0 (“no pain”) to 10 (“high pain”). Disability (Roland-Morris Disability Questionnaire
[RMDQ]): scores range from 0 (“no pain-related disability”) to 24 (“high pain-related disability”).

GE in patients with CLBP. The findings of the study based education followed by an exercise program. There
revealed that PNE plus MCE and GE led to significant is a growing body of evidence showing that central brain
improvement in pain intensity, disability, fear-avoid- mechanisms (brain abnormalities [changes in brain
ance beliefs during work and physical activity, and self- structure and function] and hyperexcitability of the
efficacy over 8 weeks in patients with CLBP. However, central nervous system [sensitization of the brain]) play
the PNE plus MCE regimen was better for pain intensity an important role in patients with CLBP.3,8 Central
and disability compared to GE. sensitization encompasses various related dysfunctions
Regarding primary outcomes (pain intensity and within the central nervous system, including altered
disability), although the implementation of both PNE sensory processing in the brain.3 Moreover, the presence
plus MCE and GE led to significant improvement, the of central sensitization implies that the brain produces
PNE plus MCE regimen was superior, which could be pain and fatigue, which can lead to disability even when
partly explained by the individualized, targeted multi- there is no real tissue damage or nociception.8 Fortu-
modal treatment employed through the use of cognitive- nately, it has been demonstrated that PNE intervention
 Pain Education and Exercise for Low Back Pain  339

Figure 3. Fear-Avoidance Beliefs (work) Questionnaire: scores range from 0 (“no fear”) to 42 (“high fear”). Fear-Avoidance Beliefs
(physical activity) Questionnaire: scores range from 0 (“no fear”) to 24 (“high fear”). Pain Self-Efficacy Questionnaire: scores range from
0 (“no confidence”) to 60 (“high confidence”). GE, group-based exercise; MCE, motor control exercise; PNE, pain neuroscience
education.

can lead to decreases in central sensitization and pain.7 (0.52 for pain and 0.49 for disability) at 3-month
Although we could not assess central sensitization in our follow-up. In contrast, the trial of Ibrahim et al.21
patients, it is hypothesized that educating patients about found that group patient education followed by MCE
pain and the fact that pain is often present without tissue was superior in ameliorating pain and disability
damage, as well as shifting patients’ opinions of pain compared to patient education or MCE alone in
toward the more biopsychosocial self-management patients with CLBP. The calculated ES for pain (1.66)
approach, could lead to decreased hyperexcitability of and disability (2.22) in the Ibrahim et al. study21 were
the central nervous system and reduced pain. The larger than in the current study, suggesting that group
addition of MCE following PNE is believed to have interventions may be more cost efficient than individ-
helped the patients gain proprioception, coordination, ualized ones.
and spinal sensorimotor control by deep muscle activa- Although the secondary outcomes (fear-avoidance
tion, which resulted in reduced pain and disabil- beliefs during work and physical activity, and self-
ity.11,19,20 efficacy) were comparable among the groups, the
In line with our findings, Malfliet et al.7 found PNE percentage changes between baseline and post-interven-
plus cognition-targeted MCE to be more effective than tion were higher in the PNE plus MCE group. Fear-
current best-evidence physiotherapy (traditional back avoidance beliefs had previously been proposed in a
and neck education and general exercises) in improv- cognitive-behavioral model of CLBP.22 It is associated
ing pain and disability in the management of chronic with safety-seeking behavior, such as avoidance/escape
spinal pain. However, our results after the intervention and hypervigilance, as a result of the dysfunctional
showed larger ES (0.66 for pain and 0.81 for disabil- interpretations of pain that can be adaptive in the acute
ity) compared to those in the Malfliet et al. study7 pain stage but paradoxically worsen the problem in the
340  RABIEI ET AL.

case of long-lasting/chronic pain. Regarding the PNE efficacy—which may have been undermined in the
plus MCE group improvement in fear-avoidance beliefs, individualized treatments.27,28
it seems that these beliefs can be targeted by educating This study is not without limitations. First, outcomes
patients and improving their understanding of pain were only assessed in the short term; hence, the long-
mechanisms.22 It can be hypothesized that when term effects of the interventions are unknown. Future
patients believe that most pain is present without any studies are needed to evaluate the long-term effects of
serious tissue damage, they would participate in more PNE plus MCE to reach strong conclusions. Second, we
physical activities with less fear of movement. To were unable to assess central sensitization due to the
support our hypothesis, Fletcher et al.,22 in their lack of a translated and validated Persian version of the
observational study, explored the relationship between Central Sensitization Inventory. Using this tool, we
knowledge of the neurophysiology of pain and fear- could find if there was any association between pain
avoidance beliefs in patients with chronic pain. Their improvement and central sensitization in the studied
result showed an association between knowledge of pain population. A translated and validated Persian version
neurophysiology and the level of fear-avoidance of the Central Sensitization Inventory will be useful,
beliefs.22 In fact, patients with higher pain knowledge along with other pain intensity measures in future
reported fewer fear-avoidance beliefs and lower per- similar studies. Lastly, brain structural and functional
ceived disability due to pain.22 changes have been observed in patients with CLBP.29,30
Self-efficacy refers to a personal belief that one thinks Using brain imaging techniques can improve our
that he or she is physically capable of and can succeed in understanding about the associations of brain changes
performing specific tasks.23 An increase in self-efficacy during the improvement of CLBP, and about the effect
beliefs has been considered as one of the key points of the interventions with and without education on
associated with pain, disability, and depressive symptom brain structure and function.
reduction.17 Moreover, it facilitates the participation of
activities and increases the effects produced by cognitive
CONCLUSION
behavioral interventions.24 Patients in the PNE plus
MCE group could have reconceptualized their pain Individualized treatment involving PNE plus MCE is
through a better understanding of it and by recognizing more effective than GE in patients with CLBP at
how threatened they were feeling because of it. In line improving pain intensity and disability, but no signifi-
with our results, previous studies have shown that PNE cant differences were observed for fear-avoidance beliefs
and individually adapted exercises are more effective and self-efficacy between the 2 groups. Although the
than usual care alone or no exercises at improving self- changes from baseline to post-intervention were larger
efficacy beliefs in patients with chronic musculoskeletal in the PNE plus MCE group in all outcomes, to
pain.25,26 In a similar vein, patients in the GE group also definitively assert the superiority of this individualized
reported improvement in fear-avoidance beliefs and self- intervention over the GE, more studies are warranted.
efficacy after the intervention. The GE in our study
included 10 patients, and they performed traditional
ACKNOWLEDGEMENT
low back–strengthening exercises under the supervision
of a physical therapist. We would like to express our deepest appreciation for
The improvement exhibited by the GE group in the the valuable assistance and contributions of all the
above-mentioned outcomes may be attributed to the patients.
grouping of the patients. Unlike in individualized
interventions where patients have more therapist–pa-
CONFLICTS OF INTEREST
tient interactions, in group interventions the patients
spend more time together with other patients, which The authors have no conflicts of interest to declare.
gives some sense of social interaction, encouragement,
and peer supports. Hypothetically, decreasing the inter-
FUNDING
action time with the therapist and increasing the time of
interaction with peers may have caused patients to This research did not receive any specific grant from the
attribute improvements to themselves—decreasing fear public, commercial funding agencies, or not-for-profit
and increasing feelings of accomplishment and self- sectors.
 Pain Education and Exercise for Low Back Pain  341

ETHICAL APPROVAL patients with chronic low back pain. Ann Rehabil Med.
2013;37:110.
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Board (DBSI109032017). analogue and McGill pain scale measures. J Manip Physiol
Ther. 2001;24:501–504.
14. Mousavi SJ, Parnianpour M, Mehdian H, Montazeri
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