A few years ago, I recall seeing many of my friends and acquaintances in physiotherapy talk about how great “Explain Pain Supercharged” was in helping them and their patients understand how pain works. Although I have not yet read the whole book, I had read a few passages when I visited Dr. Sandy Hilton and Dr. Sarah Haag at their Chicago “Mecca” two years ago in November. I loved the way Professor Lorimer Moseley and Dr. David Butler describe and illustrate the concept of pain and its research, written in a way that most fifth graders would understand.
I thought this book was the Holy Grail to help my clients with acute and chronic pain get even better. Pain education. Much of the research said it works! However, a recent study published in JAMA Neurology seemed to challenge the idea that pain education is better than having no pain education. While much of the research in pain education in the past 20 years have demonstrated benefits to those with low back pain of various intensities, pain education “ has never been tested in a placebo-controlled trial. Any benefits observed in previous trials of patient education for acute low back pain could be explained by nonspecific effects of the clinical encounter or the characteristics of the usual care comparison,” the authors wrote.
That caught my attention. I brewed another pot of coffee and continued.
In the study, the researchers—led by Dr. Adrian Traeger, who is affiliated with The University of Sydney in Sydney, Australia—recruited 202 acute low back pain patients with or without referred leg pain from physician and physiotherapist referrals. After they were randomly assigned to a pain education group or a placebo group (where the “sessions mimicked all aspects of the patient education sessions (listening, showing interest, and attention of the clinician) but without the education component.”), Traeger et al collected data after the first session, a second session a week later, and 3-, 6-, and 12-month follow-ups. The research was done at Neuroscience Research Australia.
And the results? In the primary outcome, they found that pain education was not that much effective than the placebo group at reducing pain intensity during the 3-month follow-up.
Pain Education Group Placebo Group
Baseline: 6.3 Baseline: 6.1
3 months: 2.1 3 months: 2.4
The researchers noted that in the secondary outcomes, “The odds of having a recurrence of low back pain at 12 months were lower in the patient education group than in the placebo patient education group. Pain interference and the odds of seeking health care were also lower in the patient education group at 3 months, but results for these variables were not lower at 6 or 12 months. Pain attitudes and reassurance at 1 week were higher in the patient education group.”
This seems like the pain education group fared better than the placebo. However, Dr. Traeger told Massage & Fitness Magazine, “The best way to interpret a trial is on the primary outcome. The secondary effects are interesting, but we can be much more certain about the effects on our primary outcome which was pain. As you know, there was nothing there. Until another randomised study using one of those positive secondary outcomes as their primary outcome (e.g. recurrence of low back pain) comes along, we can only conclude that this intervention is ineffective.
“Yes, we observed some effects on those secondary outcomes. We do need to be a bit careful about how we interpret those though. The positive effects could have occurred by chance. Future studies are required before we can confirm if pain education has positive effects on those outcomes.”
Dr. Traeger expressed concerns about the quality of previous studies because of how they were set up. According to a 2018 Cochrane review, 6 out of 7 studies were categorized as low or moderate quality due to lack of blinding, lack of a control group, and selective reporting (cherry-picking of data).
“Both groups received basic care from a physio or [general practitioner],” Dr. Traeger said, “and did well despite having a poor prognosis. Our results, along with evidence from other trials of adding treatments to basic care, suggest that keep it simple is probably the best approach.”
The study itself does have some limitations where future research could refine. This includes lack of clinician blinding to treatment allocation, only physiotherapists were employed as clinicians, a risk of getting a false positive in their statistical calculations, and both groups were given basic patient education in the first session which could already reduce pain in both groups.
When I asked if it is possible (or even ethical) to have a third group for comparison where physios or physicians give patients fear-mongering and inaccurate messages about back pain (e.g. “You have a slipped disc,” or “Your pelvis is out of alignment and that’s causing your pain.”).
“Great question. [It] would be a tough one to explain to ethics. There is a widespread assumption that those labels are harmful. I think we still have a lot to learn about the benefits and harms of such labels and fear-mongering.”
While a few therapists on social media expressed their “Oh, bummer!” moment, this study does not say that giving pain education is useless or therapists should abandon it. It just says it is not superior to taking the time to listen and give your time and attention to patients and clients. I still think it is important to let them know that pain does not always equate to the degree of tissue damage and other misconceptions about pain and disability, and there are many conservative and inexpensive ways to manage or even alleviate pain, such as exercise, getting enough sleep, getting some TLC, and stress management. How we educate and what we deliver would depend on the individual patient or client in front of us.
1. Traeger AC, Lee H, Hübscher M, et al. Effect of Intensive Patient Education vs Placebo Patient Education on Outcomes in Patients With Acute Low Back PainA Randomized Clinical Trial. JAMA Neurol. Published online November 05, 2018. doi:10.1001/jamaneurol.2018.3376
2. Tegner H, Frederiksen, Esbensen BA3, Juhl C. Neurophysiological Pain Education for Patients With Chronic Low Back Pain: A Systematic Review and Meta-Analysis. Clin J Pain. 2018 Aug;34(8):778-786. doi: 10.1097/AJP.0000000000000594.