Sensorimotor retraining alleviates chronic back pain

Key takeaways

• Sensorimotor retraining was designed to change how people with chronic lower back pain move during activities, think about their body in pain and process sensory information from their back.
• The intervention significantly lowered pain intensity. After 18 weeks, mean pain intensity measured on an 11-point rating scale decreased from 5.6 to 3.1 in the intervention group.
• At 26 weeks, 18.3% of participants in the intervention group met the criterion for recovery.

A novel treatment designed to help patients with chronic lower back pain change their perceptions of pain and function through neural processing significantly lowered pain intensity and improved disability, data show.

Lower back pain affected about 52 million Americans in 2019 and has been the top cause of disability burden worldwide since 1990, according to James McAuley, PhD, a professor at the University of New South Wales’s School of Health Sciences in Australia, and colleagues. A previous meta-analysis showed that about one-third of people with low back pain faced persistent pain and disability 3 months after the onset of symptoms and “were unlikely to recover completely within 1 year,” McAuley and colleagues wrote in JAMA.

“New, effective treatments are needed for low back pain,” they wrote. “Graded sensorimotor retraining is a novel intervention designed to alter how people think about their body in pain, how they process sensory information from their back, and how they move their back during activities.”

The concept of graded sensorimotor retraining was based on research that suggests the nervous system of people with chronic back pain “behaves in a different way from people who have a recent injury to the lower back,” according to a press release accompanying the study.

“People with back pain are often told their back is vulnerable and needs protecting. This changes how we filter and interpret information from our back and how we move our back,” McAuley said in the release. “Over time, the back becomes less fit, and the way the back and brain communicate is disrupted in ways that seem to reinforce the notion that the back is vulnerable and needs protecting. The treatment we devised aims to break this self-sustaining cycle.”

For the randomized clinical trial, McAuley and colleagues assigned 276 participants to a control group, in which participants received 12 weeks of sham treatment, or the intervention group, where they received the 12-week sensorimotor retraining course known as RESOLVE. The participants reported experiencing back pain for a median of 5 years. At baseline, their mean pain intensity was 5.7 on a scale from 0 to 10 points, with 0 representing no pain and 10 being the worst pain.

RESOLVE

The RESOLVE intervention was delivered by a physiotherapist or exercise physiologist during 12 sessions that lasted up to 1 hour, according to the researchers. The participants were also encouraged to complete a home treatment component for 30 minutes five times per week.

“The primary intention was to help people in pain understand that it was safe and helpful to move (step 1), feel safe to move (step 2), and experience that it was safe to move (step 3) as they progressed toward reengagement with meaningful functional goals,” McAuley and colleagues wrote.

During the first session, contemporary pain education was offered through graphical media, video, metaphor and narrative and continued for the duration of the intervention, according to the researchers. During sessions two through 12, the participants received graded premovement treatments in the clinic that were continued at home. These treatments involved sensory precision training and mental rehearsal of movement.

“In the sixth session, participants began graded movement training in the clinic and continued at home, starting with simple spinal movements before progressing toward more complex exercises, such as squatting, lunging and lifting, which continued for the duration of the intervention,” the researchers wrote.

Changes in pain intensity

The study found that after 18 weeks, mean pain intensity decreased from 5.6 to 3.1 points in the intervention group, which the researchers described as “modest” but “clinically meaningful” improvement compared with the control group’s reduction from 5.8 to 4 points (estimated mean difference, 1; 95% CI, 1.5 to 0.4). Further, participants in the intervention group saw significantly improved disability (2.6 points; 95% CI, 3.9 to 1.3).

The researchers also found at the 18-week follow up that 68% of those in the intervention group had at least a 30% decrease in pain intensity compared with 49.6% in the control group (risk difference, 20%; 95% CI, 10-30; RR = 1.4; 95% CI, 1.1-1.7).

“What we observed in our trial was a clinically meaningful effect on pain intensity and a clinically meaningful effect on disability. People were happier, they reported their backs felt better and their quality of life was better,” McAuley said in the release.

When following up at 26 weeks, 18.3% of participants in the intervention group met the criterion for recovery compared with 9.8% in the control group, according to the researchers (risk difference, 10%; 95% CI, 0-20]; RR = 1.9; 95% CI, 1-3.5).

“It also looks like these effects were sustained over the long term; twice as many people were completely recovered. Very few treatments for low back pain show long-term benefits, but participants in the trial reported improved quality of life one year later,” McAuley said in the release.

An advantage from the intervention is that the rates of adverse events were low, the researchers wrote, a contrast to other interventions like medications, spinal cord stimulation or surgery.

Another advantage is that, when undergoing sensorimotor training, patients can see that their back and brain are not communicating effectively, then experience an improvement in this communication, Ben Wand, BAppSc(Physio), GradDip(ExSpSc), MAppSc(manip.physio), PhD, the clinical director on the trial and a professor at the University of Notre Dame Australia, said in the release.

“We think this gives them confidence to pursue an approach to recovery that trains both the body and the brain,” he said.

References:

• An effective new treatment for chronic back pain targets the nervous system. https://www.eurekalert.org/news-releases/960463. Published Aug. 2, 2022. Accessed Aug. 22, 2022.
• Bagg M, et al. JAMA. 2022;doi:10.1001/jama.2022.9930.
• The Global Burden of Low Back Pain. https://www.iasp-pain.org/resources/fact-sheets/the-global-burden-of-low-back-pain/. Published July 9, 2021. Accessed Aug. 22, 2022.