Physiotherapy Theory and Practice

An International Journal of Physical Therapy

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/iptp20

The effectiveness of pain neuroscience education

combined with manual therapy and home
exercise for chronic low back pain: A single-blind
randomized controlled trial

Ismail Saracoglu , Meltem Isintas Arik , Emrah Afsar & Hasan Huseyin
Gokpinar

To cite this article: Ismail Saracoglu , Meltem Isintas Arik , Emrah Afsar & Hasan Huseyin
Gokpinar (2020): The effectiveness of pain neuroscience education combined with manual
therapy and home exercise for chronic low back pain: A single-blind randomized controlled trial,
Physiotherapy Theory and Practice, DOI: 10.1080/09593985.2020.1809046

To link to this article: https://doi.org/10.1080/09593985.2020.1809046

Published online: 19 Aug 2020.

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PHYSIOTHERAPY THEORY AND PRACTICE
https://doi.org/10.1080/09593985.2020.1809046

The effectiveness of pain neuroscience education combined with manual therapy

and home exercise for chronic low back pain: A single-blind randomized
controlled trial
Ismail Saracoglua, Meltem Isintas Arika, Emrah Afsara, and Hasan Huseyin Gokpinarb
a
Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Kutahya Health Sciences University, Kutahya, Turkey;
b
Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Kutahya Health Sciences University, Kutahya, Turkey

ABSTRACT ARTICLE HISTORY

Objectives: The aim of this study was to investigate the short- and mid-term effects of pain Received 14 January 2020
neuroscience education (PNE) combined with manual therapy (MT) and a home exercise program Revised 28 May 2020
(HEP) on pain intensity, back performance, disability, and kinesiophobia in patients with chronic low Accepted 12 July 2020
back pain (CLBP). Methods: This study was designed as a prospective, randomized, controlled, KEYWORDS
single-blind study in which 69 participants were randomly assigned to three groups. Participants Chronic low back pain; home
in Group 1 received PNE, MT, and the HEP, while Group 2 received MT and the HEP. Participants in exercises; pain neuroscience
the control group did the HEP only. All interventions lasted 4 weeks. The participants’ pain intensity, education; manual therapy;
disability, low back performance, and kinesiophobia were assessed. All assessments were executed pain intensity
before intervention, at 4 weeks, and at 12 weeks post-intervention by the same blinded phy­
siotherapist. A mixed model for repeated measures was used for each outcome measure. Results:
Analysis of pain level (p < .05), back performance (p < .05), disability (p < .05) and kinesiophobia
(p < .05) revealed significant time, group, and time-by-group interaction effects. The participants in
Group 1 exhibited greater improvement in terms of pain intensity and kinesiophobia compared to
the participants in Group 2 and the control group. Level of disability was significantly decreased in
both Group 1 and Group 2 compared to the control group. Conclusion: This study suggests that
a multimodal treatment program combining PNE, MT, and HEP is an effective method for improving
back performance and reducing pain, disability, and kinesiophobia in the short (4 weeks) and
midterm (12 weeks).

Introduction involves a continuum of skilled passive movements to

the joint complex that are applied at varying speeds and
Chronic low back pain (CLBP) is a common health
amplitudes with the intent to restore optimal motion,
condition in both developed and developing countries
function, and/or to reduce pain by increasing the exten­
and causes severe physical, psychological, and economic
sibility of articular and periarticular structures
losses. Increased duration and cost of treatment in CLBP
(Mintken, DeRosa, Little, and Smith, 2008).
lead to greater health expenditures (Hong, Reed, Novick,
Mobilization also has neurophysiological effects such
and Happich, 2013). Moreover, CLBP causes labor loss
as altered alpha motor neuron activity and autonomic
and inefficiency, resulting in secondary economic losses
response systems and increased blood levels of b-endor­
(Geurts et al., 2018). CLBP is frequently associated with
phin and serotonin, which have been shown to occur
disability due to both physiological and psychological
throughout the nervous system via peripheral, spinal,
reasons such as prolonged pain, limitation of activities of
and supraspinal mechanisms (Bialosky et al., 2009). In
daily living, reduced performance, fear-avoidance
addition, evidence-based guidelines for the management
beliefs, and kinesiophobia (Altuğ et al., 2015; Storheim
of CLBP emphasize the importance of a physically active
et al., 2003).
lifestyle and active rehabilitation; as a result, patients are
Pharmacological treatments, invasive treatment
typically prescribed home exercise programs (HEP)
methods, biophysical and electrotherapeutic modalities,
(Savigny et al., 2009). However, non-surgical conserva­
exercise therapy, and manual therapy (MT) are among
tive treatments including MT and HEP for CLBP have
the therapeutic approaches frequently used in CLBP
small to moderate effect sizes (Keller, Hayden,
(Grabois, 2005; Savigny, Watson, and Underwood,
Bombardier, and Van Tulder, 2007). Since these
2009). Mobilization is one of the MT techniques and

CONTACT Ismail Saracoglu fzt.saracoglu@hotmail.com Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Kutahya Health
Sciences University, Kutahya 43100, Turkey
© 2020 Taylor & Francis Group, LLC
2 I. SARACOGLU ET AL.
treatment methods mostly target the painful anatomical
region and focus on the biological aspect of pain, there is
a need to develop more effective interventions (Bialosky
et al., 2014; Coulter et al., 2018; Louw, Nijs, and
Puentedura, 2017; Scholten-Peeters et al., 2013).
In recent years, cognitive patient education has been
widely used in conjunction with conventional treatment
methods in the management of CLBP (Moseley, 2002).
Pain neuroscience education (PNE) is one of various
cognitive therapy methods and is often implemented
together with MT and exercise (Louw, Nijs, and
Puentedura, 2017; Puentedura and Flynn, 2016). In
PNE, the patient is taught about the physiology of
pain, nociplastic pain, representation of the different
body regions in the brain, pain-related changes in body
perception, and the psychosocial dimensions of pain
(Cox, Louw, and Puentedura, 2017; Meeus et al., 2010).
The main goal of PNE is to change the patient’s mis­
conceptions and maladaptive thoughts regarding pain
(Meeus et al., 2010). PNE uses neurophysiological infor­
mation to teach the patient that pain can arise even in
the absence of tissue injury and can be overprotective
(Moseley and Butler, 2015).
Several studies evaluating the efficacy of PNE in
CLBP showed that PNE combined with MT and exercise
had favorable statistical effects on levels of pain and
disability (Moseley, 2002; Moseley, Nicholas, and
Hodges, 2004; Nijs et al., 2014). A systematic review
also showed that PNE is a promising treatment option
for pain, physical-function, psychological-function, and
social-function in patients with CLBP (Clarke, Ryan,
and Martin, 2011). However, authors have pointed out
a lack of randomized controlled studies and stated that
further research on the PNE is needed (Louw, Zimney,
Puentedura, and Diener, 2016). Besides, there are few
studies comparing the effect of MT, HEP, and PNE in
the literature. Therefore, we conducted this three-arm
randomized, controlled, single-blind study to investigate
the short- and mid-term effects of: 1) PNE + MT +
HEP; 2) MT + HEP; and 3) HEP alone on pain intensity,
back performance, disability, and kinesiophobia in
patients with CLBP, with the specific aim of testing the
hypothesis that PNE increases the effectiveness of MT in
addition to HEP in patients with CLBP.
Methods
Trial design
This study was designed as a prospective, three-arm,
randomized, controlled, single-blind study. Data collec­
tion was performed between February and October 2018
at Kutahya Health Sciences University Physical Therapy
Hospital. The study was approved by the Kutahya Health
Sciences University Clinical Research Ethics Committee
(#2017-14/4). The study was registered retrospectively at
ClinicalTrials.gov (Registration number: NCT03886636).
The methods of this study were reported using the
CONSORT statement (Moher et al., 2012).
Participants
Recruitment and setting
Participants experiencing CLBP who presented to the
department of physiotherapy of Kutahya Health
Sciences University Hospital during the study period
were screened for eligibility by an independent phy­
sician and were subsequently invited to participate in
the study. Low back pain (LBP) was defined as pain
localized below the costal margin and above the infer­
ior gluteal folds (Koes, Van Tulder, and Thomas,
2006). The participants, who were not referral cases
but presented directly to our center, were examined
by one of the researchers (H.H.G., specialist in phy­
sical medicine and rehabilitation) for inclusion and
exclusion criteria. All participants were informed in
advance about the procedures and assessments to be
performed in the study. Those who agreed to partici­
pate signed consent forms.
Inclusion criteria
The study included participants 18–65 years of age who
had complaints of LBP for at least 6 months and
reported pain intensity of 5 or greater according to the
numeric pain rating scale (NPRS).
Exclusion criteria
Participants with previous spine or lower extremity sur­
gery, severe osteoporosis, spondylo-arthropathy, spon­
dylolisthesis, lumbar stenosis, or a systemic
inflammatory disease other than LBP, and those who
were illiterate were excluded from the study.
Study procedures
After randomization into the three study groups, the
participants were evaluated by a blinded researcher (E.
A.), then underwent 4 weeks of treatment with a different
researcher (I.S.). They were reevaluated by the same
blinded researcher (E.A.) at 4 weeks and again at
12 weeks. Study phases and arms were defined as fol­
lows: Intervention Arm: Group 1 – Participants in
Group 1 received PNE, MT, and the HEP; Intervention
Arm: Group 2 – Participants in Group 2 received MT
and the HEP; and Control Arm: Group 3 – Participants
in the control group did the HEP program only.

Interventions
Manual therapy
In our study, MT was individualized according to each
patient’s response to treatment, as described by Cook
(2011). The clinician identifies and performs the joint
mobilization techniques from those described below
that improve the patient’s symptoms. Joint mobilization
techniques used in this study included low velocity, mid-
range, posterior-to-anterior force to the lower lumbar
spine in a prone position (Ali, Sethi, and Noohu, 2019);
low velocity, mid-range, right or left rotational force to
the lower lumbar spine on the upper lumbar spine in
a right or left side-lying, right or left lower thoracic
lumbar side-bent position (Sato, Koumori, and
Uchiyama, 2012); and mobilization with movement
techniques for lumbar spine (Hing et al., 2015). The
individualized treatment program was implemented in
a total of 8 sessions, held twice a week for 4 weeks. Each
mobilization session lasted 30 minutes. The entire treat­
ment program was carried out by the same physiothera­
pist (I.S.) who holds an MSc degree and has 10 years of
experience in MT.
Pain neuroscience education
PNE was carried out using the method recommended by
Louw, Nijs, and Puentedura (2017) The content of the
education is shown in Figure 2. Metaphors, anecdotes,
and pictures were used in PNE. A slide presentation
(PowerPoint, Microsoft Corp., Redmond, WA, USA)
prepared by the instructor was used in all sessions.
A total of 4 PNE sessions were held, once each week,
before an MT session. The PNE sessions were conducted
by the same physiotherapist (I.S.) who provided MT
sessions and had completed PNE training from the
International Spine and Pain Institute. The sessions
were conducted in face-to-face, one-on-one sessions
lasting 40–45 minutes.
Home exercise program
All participants in all groups were assigned the HEP
developed by Koumantakis, Watson, and Oldham
(2005). The program aims to increase strength and flex­
ibility of the abdominal, erector spinae, gluteal, quad­
riceps, and hamstring muscles. The program begins with
lumbar and pelvic stretching and warm-up exercises,
followed by strengthening exercises.
All exercises were explained once and performed
under the supervision of the physiotherapist. The partici­
pants were then asked to perform all of the exercises with
10 repetitions of each exercise 3 times a day for 4 weeks.
None of the participants received feedback regarding the
practice of HEP over the following 4 weeks. At the first
PHYSIOTHERAPY THEORY AND PRACTICE 3
follow-up session (at 4 weeks), the physiotherapist con­
firmed their correct performance of the exercises again.
Outcomes
Data regarding the participants’ age, height, body
weight, body mass index, education level, and duration
of symptoms were recorded on a previously prepared
assessment form in face-to-face interviews. The partici­
pants’ pain level, disability, low back performance, and
kinesiophobia were then assessed using the methods
described below. All assessments were repeated before
treatment, at 4 weeks, and at 12 weeks by the same
physiotherapist (E.A.) who was blind to the interven­
tions. Pain intensity was the primary outcome measure,
whereas back performance, disability, and kinesiophobia
were the secondary outcome measurements.
Assessment of pain intensity
The numeric pain rating scale (NPRS) was used to assess
the participants’ pain levels. In the NPRS, participants
are asked to verbally rate the severity of their pain on
a scale from 0 to 10 points. Clinometric characteristics of
the NPRS are adequately established (Childs, Piva, and
Fritz, 2005) and the test–retest reliability of the scale was
found to be high (r = 0.82) in patients with chronic pain
(Jensen, Turner, Romano, and Fisher, 1999). The mini­
mal clinical important difference (MCID) for NPRS is
reported as 2 points (Childs, Piva, and Fritz, 2005).
Assessment of back performance
Performance was assessed using the Back Performance
Scale (BPS) described by Strand, Moe-Nilssen, and
Ljunggren (2002). The BPS shows moderate correlation
(Spearman rho = 0.45, P < .01) with the Roland Morris
Disability Questionnaire. Intertester reliability of the
BPS was very high (intraclass correlation coeffi­
cient = 0.99) and test-retest reliability was also high
(intraclass correlation coefficient = 0.91) (Magnussen,
Strand, and Lygren, 2004). The BPS includes 5 tests of
trunk mobility (sock test, pick-up test, roll-up test, fin­
gertip-to-floor test, and lift test). Each test is scored from
0 to 3 based on the observed level of physical perfor­
mance, and total score ranges from 0 to 15 points
(Maras, Citaker, and Meray, 2019). High score indicates
poor performance.
Assessment of disability
The participants’ level of disability was evaluated using
the Turkish adaptation of the Oswestry Disability Index
(ODI), which was developed by Fairbank, Couper,
Davies, and O’Brien (1980). The scale comprises 10
items, each with 6 options worth 0 to 5 points. For
4 I. SARACOGLU ET AL.
each item, participants are asked to mark the option that
best describes their current condition. A high total score
indicates more severe disability (Yakut et al., 2004). The
MCID for ODI is reported as 10 points (Hägg, Fritzell,
and Nordwall, 2003).
Assessment of Kinesiophobia
The Tampa Scale for Kinesiophobia (TSK) was used for
the assessment of kinesiophobia. The TSK is a 17-item
questionnaire developed to measure fear of movement/
re-injury. The scale includes injury/re-injury and fear-
avoidance parameters in work-related activities. The
items are rated on a 4-point Likert-type scale (1 = defi­
nitely disagree, 4 = completely agree) and the total score
is between 17 and 68 points. Higher total score indicates
higher level of kinesiophobia (Yilmaz, Yakut, Uygur,
and Uluğ, 2011). The MCID for TSK is reported as 8
points (Lüning Bergsten, Lundberg, Lindberg, and
Elfving, 2012).
Sample size
The required sample size was calculated using G*Power
software (Faul, Erdfelder, Lang, and Buchner, 2007).
A repeated-measures analysis of variance (ANOVA)
with interaction within-between factors was used. The
NPRS scores was the primary outcome measure. The
effect size of the NPRS was estimated to be moderate
(effect size = 0.25) for the group × time interaction. For
statistical power of 0.80 and an α level of 0.05, it was
estimated that a sample size of 39 participants (13 parti­
cipants in each group) was necessary. The enrollment
goal was set at 45 participants to account for possible
loss to follow-up of 15%.
Randomization
The random allocation sequence was generated using
StatsDirect software (StatsDirect Ltd; Cheshire,
England) in one block. Opaque, sealed, and stapled
envelopes were used for concealment of allocation
until the moment of intervention. The participants
were allocated to the groups by a researcher (M.I.A.)
who did not apply the intervention or evaluate the
outcomes.
Blinding
The principal investigator was not involved in the treat­
ment sessions of the participants and was blinded to
group allocation while making the assessments and plot­
ting the data. The participants were asked not to reveal
any information about group allocation to the principal
investigator (E.A.) performing the assessments.
Statistical methods
At the end of the study, the data were analyzed using
SPSS 18.0 statistical package software. All variables were
assessed for normal distribution using Kolmogorov–
Smirnov or Shapiro–Wilk test. Baseline values of all
assessed parameters were compared between groups
using one-way ANOVA. A mixed-model repeated mea­
sures ANOVA was used to analyze changes in pain
intensity, back performance, disability level, and kine­
siophobia in the treatment and control groups. Post-hoc
tests were performed using Tukey tests. A p value < .05
was considered statistically significant. Partial eta-
squared (η2) calculated by SPSS, was used to gauge effect
size. η2 values less than 0.01 reflect a small effect size,
0.06 reflects a medium effect size, and values over 0.14
reflects a large effect size (Cohen, 1988).
Results
Of the initial group of 69, 12 participants were excluded
from the study because they did not comply with the
treatment program and/or assessments. A total of 57
participants completed their assigned treatment pro­
gram and post-treatment evaluations. Group 1 included
20 participants (mean age: 39.67 ± 13.71 years), Group 2
included 19 participants (mean age: 41.38 ± 12.70 years),
and the control group included 18 participants (mean
age: 40.25 ± 9.70 years) (Figure 1). Age, sex, height, body
weight, body mass index, duration of LBP, and educa­
tion level of the study participants are shown in Table 1.
No significant differences were detected between the
groups in terms of age (p = .89), height (p = .51), body
weight (p = .08), body mass index (p = .22), or duration
of LBP (p = .39). The groups also had similar baseline
scores for pain intensity, back performance, disability,
and kinesiophobia (Table 2).
Primary outcome measure
The results of ANOVA for pain intensity revealed sta­
tistically significant differences for the group factor [F
(2,54) = 9.37; p < .001; ŋ2 = 0.25], time factor [F
(2,108) = 145.93; p < .001, ŋ2 = 0.73], and group ×
time interaction [F(4,108) = 14.85; p < .001; ŋ2 = 0.35]
(Table 2). Post-hoc test showed that Group 1 had sig­
nificantly lower NPRS values than Group 2 (p = .01) and
the control group (p < .001) (Table 3, Figure 3). There
was no statistically significant difference between Group
2 and the control group (p = .44) (Table 3).
 Assessed for eligibility (n=81)

Enrollment
Excluded (n=12)
• Not meeting inclusion criteria (n=8)
• Declined to participate (n= 3)
• Other reasons (n=1)

Randomized (n= 69)

Allocation

Allocated to intervention Allocated to intervention Allocated to intervention

(n=23) (n=23) (n=23)

GROUP 1 GROUP 2 CONTROL

(Pain neuroscience education (Manual therapy+ home (Home exercises)
+ manual therapy+ home exercises )
exercises )

*Received allocated (n=23) *Received allocated (n=23) *Received allocated (n=23)

Follow-Up

Lost to follow-up (n=3) Lost to follow-up (n=4) Lost to follow-up (n=5)

*Discontinued intervention (n=2) *Discontinued intervention (n=2) *Discontinued intervention (n=3)
*Discontinued measurement (n=1) *Discontinued measurement (n=2) *Discontinued measurement (n=2)

Analysis

Analysed (n=20) Analysed (n=19) Analysed (n=18)

PHYSIOTHERAPY THEORY AND PRACTICE

Figure 1. Study layout.

5
6 I. SARACOGLU ET AL.

1. session Peripheral neuropathic pain, peripheral nerve

sensitization, allodynia, central sensitization,
hyperalgesia

2. session Neuroplasticity, spreading pain, central

sensitization, hyperalgesia, allodynia

3. session Stress biology, immune response, emotional

overload, fear, catastrophization and pain

4. session How to cope with pain? The role of exercise

and manual therapy

Figure 2. The content of neuroscience pain education.

Table 1. Demographic characteristics of groups.

Group 1 (n = 20) Group 2 (n = 19) Control (n = 18)
(Mean ± SD) (Mean ± SD) (Mean ± SD)
Height (cm) 167.26 ± 8.03 170.95 ± 11.44 168.50 ± 7.84
Weight (kg) 72.28 ± 10.38 81.71 ± 17.23 78.40 ± 12.64
BMI (kg/m2) 25.75 ± 3.83 27.79 ± 4.25 27.70 ± 4.68
Duration of pain (months) 28.14 ± 16.62 34.60 ± 15.37 31.50 ± 13.60
Sex n n n
Female 12 10 10
Male 9 11 10
Education
Primary school 2 9 10
Middle school 7 2 4
High school 6 4 4
University 6 6 2
SD: Standard Deviation; n: Numbers of participants; cm: Centimeter; kg: Kilogram; kg/m2: Kilogram/square meter.

Table 2. Changes over time within and between groups.

Outcome Baseline F (p) F (p) F (p)
Measures/Groups (Mean±SD) At 4th weeks (Mean±SD) At 12th weeks (Mean±SD) Group effect Time effect Interaction effect
NPRS (0-10)
Group 1 7,29 ± 1,41 3,05 ± 1,50 2,09 ± 1,64 9,37 145,93 14,85
(p < .001) (p < .001) (p < .001)
Group 2 7,58 ± 1,47 4,42 ± 1,78 4,52 ± 1,84
Control 7,32 ± 1,48 5,89 ± 2,03 5,47 ± 1,95
BPS (0-15)
Group 1 7,35 ± 2,68 3,15 ± 1,72 2,50 ± 1,73 1,52 157,80 23,67
(p = .22) (p < .001) (p < .001)
Group 2 6,31 ± 2,38 4,00 ± 2,10 3,73 ± 2,05
Control 6,27 ± 3,26 5,33 ± 2,84 5,22 ± 2,79
ODI (0-100)
Group 1 34,45 ± 7,39 22,80 ± 6,77 19,90 ± 5,72 5,52 74,32 13,30
(p < .001) (p < .001) (p < .001)
Group 2 32,00 ± 6,87 25,00 ± 7,88 25,89 ± 7,37
Control 34,74 ± 8,55 31,77 ± 9,27 32,33 ± 8,49
TSK (17-68)
Group 1 44,35 ± 4,30 35,55 ± 5,75 35,19 ± 3,99 13,73 38,32 13,14
(p < .001) (p < .001) (p < .001)
Group 2 45,10 ± 4,45 41,63 ± 5,23 42,21 ± 5,04
Control 45,55 ± 4,10 44,94 ± 4,70 44,88 ± 5,10
SD: Standard Deviation; n: Numbers of participants; NPRS: Numeric pain rating scale, BPS: Back performance scale, ODI: Oswestry Disabiliy Index, TSK: Tampa
Scale for Kinesiophobia, F: Spanova statistics, p: Significance level.
 PHYSIOTHERAPY THEORY AND PRACTICE 7

Table 3. Mean difference between groups for outcomes.

Group Mean Difference (95% CI) Significance (p)
NPRS (0-10) Control vs Group 2 0,58 (−0,57 to 1,73) p = .44
Control vs. Group 1 1,98 (0,84 to 3,11) p < .001*
Group 2 vs Group 1 1,39 (0,27 to 2,51) p = .01*
BPS (0-15) Control vs Group 2 0,93 (−0,90 to 2,76) p = .44
Control vs. Group 1 1,28 (−0,53 to 3,09) p = .21
Group 1 vs Group 2 0,35 (−1,13 to 1,83) p = .88
ODI (0-100) Control vs Group 2 5,38 (−0,13 to 10,90 p = .05*
Control vs. Group 1 7,30 (1,85 to 12,75) p < .001*
Group 2 vs Group 1 1,91 (−3,46 to 7,29) p = .67
TSK (17-68) Control vs Group 2 2,14 (−1,10 to 5,39) p = .26
Control vs. Group 1 6,78 (3,57 to 9,98) p < .001*
Group 2 vs Group 1 4,63 (1,47 to 7,80) p < .001*
NPRS: Numeric pain rating scale, BPS: Back Performance Scale, ODI: Oswestry Disability Index, TSK: Tampa Scale of Kinesiophobia, CI: confidence interval, *:
p < .05

Secondary outcome measures reported that adding MT to HEP did not appear to
improve pain or disability in the short- or long-term
BPS scores decreased significantly in all three groups,
for patients with CLBP. This discrepancy in results
with no statistically significant difference between the
might be related to differences in the type and intensity
groups (p > .05) (Table 2).
of the exercise programs used in combination with MT.
The results of the ANOVA revealed a statistically
In the present study, back performance was signifi­
significant effect for the group factor ODI [F
cantly improved at all time points in both the MT + HEP
(2,54) = 5.52; p < .001; ŋ2 = 0.17] and TSK [F
group and HEP only group, but unlike in disability,
(2,54) = 13.73; p < .001; ŋ2 = 0.33] (Table 2). ODI scores
there was no statistical difference between the groups.
were significantly lower in Group 1 (p < .001) and Group
It is not surprising that self-reported assessment of dis­
2 (p = .05) compared to the control group (Table 3,
ability and direct measurements of functional status are
Figure 3). TSK scores were significantly lower in
not correlated, as self-reported disability is subject to
Group 1 compared to Group 2 (p < .001) and the control
bias in various forms associated with psychological fac­
group (p < .001) (Table 3, Figure 3).
tors and patient perceptions of disability (Wand et al.,
2010).
Discussion Kinesiophobia is not often evaluated as an outcome
measure when assessing the effects of MT and HEP in
In our study, a multimodal program including PNE,
patients with CLBP; however, it might be a predictor or
MT, and HEP was associated with clinically significant
risk factor of CLBP (Gheldof et al., 2007; Swinkels-
improvement in: pain level (5.2 points) (Childs, Piva,
Meewisse et al., 2006). This study reveals that MT +
and Fritz, 2005); disability (14.5 points) (Hägg, Fritzell,
HEP showed no superiority to HEP alone in reducing
and Nordwall, 2003); low back performance (4.8 points);
kinesiophobia. However, de Oliveira Meirelles, de
and kinesiophobia (9.1 points) (Lüning Bergsten,
Oliveira Muniz Cunha, and da Silva (2020) found that
Lundberg, Lindberg, and Elfving, 2012) in a follow-up
MT with a supervised exercise program caused greater
period of 12 weeks. In addition, the combination of
improvements in kinesiophobia compared to the super­
PNE, MT, and HEP resulted in greater improvement
vised exercise program alone. These conflicting results
in terms of pain intensity and kinesiophobia compared
may be attributable to differences in the content of the
to MT and HEP or the HEP alone.
MT interventions or the fact that the exercise program
in their study was supervised.
MT ± HEP versus HEP only
The results of our study indicate that MT + HEP was
PNE with MT ± HEP versus MT ± HEP
associated with clinically significant improvement in
pain intensity, whereas HEP alone resulted in no clinical The main aim of this study was to determine whether
improvements in the 12-week follow-up period. PNE together with MT and HEP was superior to the
Furthermore, the MT + HEP group showed greater combination of MT and HEP. There is a limited number
improvement in disability compared with HEP alone. of studies on this subject in the literature. Beltran-
These results are similar to those of a previous study Alacreu, López-de-Uralde-Villanueva, Fernández-
(Bronfort et al., 2014) comparing MT combined with Carnero, and La Touche (2015) divided 45 patients
HEP versus HEP alone. However, Schulz et al. (2019) with chronic neck pain into 3 groups: the first group
 8

Change of BPS Scores

a b
8
Change of NPRS Scores
I. SARACOGLU ET AL.

8
7
7
6
6
5
5

BPS Scores
4

NPRS Scores
4

3
3

2 2
Baseline At 4 weeks At 12 weeks Baseline At 4 weeks At 12 weeks

c Change of ODI Scores d

Change of TSK Scores
35
47
33
31 45
29
43
27
25
41
23

ODI Scores
TSK Scores

21 39
19
37
17
15 35
Baseline At 4 weeks At 12 weeks Baseline At 4 weeks At 12 weeks

Figure 3. Changes in scores on the NPRS, BPS, ODI and TSK.


had MT alone, the second group had MT and PNE, and
the third group had MT and PNE with exercise. The
authors reported significant improvement in all groups
at 4 weeks, whereas the effects were greater in the group
who had combined MT, PNE, and exercise at 8 weeks.
Similarly, we observed significant improvements in all
parameters both at 4 and 12 weeks in patients who
received PNE combined with MT and HEP. Moreover,
we found that PNE in addition to MT and HEP is a more
effective approach than MT + HEP in terms of reducing
pain intensity and kinesiophobia in patients with CLBP.
The greater improvement in pain intensity and kinesio­
phobia scores of participants who received PNE may be
related to the content of PNE, which includes the fear-
avoidance model proposed by Vlaeyen and Linton
(2000). This model explains stress, anxiety, fear avoid­
ance, and kinesiophobia and their effects on the pain
experience. Awareness of this relationship could be
expected to reduce symptoms and kinesiophobia.
Based on this, it can be concluded that the implemen­
tation of MT and HEP alone might be inadequate in the
management of CLBP patients. Therefore, instead of
implementing MT, exercise, and other conventional
physiotherapy practices alone, combining them with
cognitive and behavioral approaches such as PNE may
provide greater benefit in patients with CLBP or other
chronic pain.
Limitations
Our study has certain limitations. The participants in
this study had varying levels of education but the
authors did not take into account the potential impact
of this variation in PNE and the HEP. Secondly, the
authors could not assess whether the participants
adhered to the HEP, as participants did not record
exercise logs regularly. This may have affected the
results, as there may be a difference between the three
groups regarding adherence of the HEP. In addition,
because MT was provided pragmatically rather than
prescriptively, it was different for each participant
within the same group. Moreover, participants in PNE
+ MT + HEP group received extra information about the
role of exercise in pain management during all PNE
sessions, whereas participants in other groups did not
receive this information. This could also have affected
compliance with the HEP.
Conclusion
Our results suggest that a multimodal program including
PNE, MT, and HEP significantly improves pain level,
disability, low back performance, and kinesiophobia at
PHYSIOTHERAPY THEORY AND PRACTICE 9
both 4 weeks and 12 weeks of follow-up. In addition,
when compared to MT and HEP or HEP alone, the
combination of PNE, MT, and HEP is associated with
greater improvement in terms of pain intensity and kine­
siophobia. Further randomized, controlled studies should
be planned to investigate the long-term effect of multi­
modal treatment programs including PNE.
Conflicts of interest
No conflict of interest is declared by the authors.
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