nCSP management should aim at achieving and maintaining a clinically important reduction in pain and disability, with optimal cost-effectiveness and minimal inconveniences. Yet, systematic reviews on the most frequently applied primary care treatments for nCSP (i.e. mobilization, manipulation, exercise therapy, back schools, NSAID's, TENS, etc.) report small, short-term benefits when compared to no, sham or other forms of treatment.4,8–12 Physiotherapy in nCSP is often limited to a biomedical (i.e. neuromuscular training) or psychological model (i.e. graded exposure, graded activity, etc.), without accounting for the underlying pain mechanisms and the present understanding of modern pain neuroscience.13 These types of therapy are focused either on input mechanisms (treating peripheral elements like joints and muscles) or output mechanisms (motor control), while there is less attention for the well documented abnormalities in central nociceptive processing mechanisms 14–22.

These central nociceptive processing abnormalities include alterations in brain activity and morphology, hyperexcitability of the central nervous system and central sensitization.13,22–26 This knowledge provides arguments for choosing a challenging new direction by developing novel clinical strategies targeting the brain and aiming at normalizing central alterations. This approach may increase the effect sizes and socioeconomic impact of treatment of nCSP.

Inspired by this state of the art, treatment should aim at addressing central nervous system dysfunctions,27,28 psychosocial factors,13,29 as well as peripheral dysfunctions in a broader biopsychosocially-driven framework. Although the problem in nCSP is not related to a dominant ‘input’ mechanism, there is still compelling evidence for impaired motor control.30–35 Therefore, therapy should focus primarily at central nociceptive processing problems, in a balanced combination with targeting specific ‘output’ mechanisms given the maladaptive movement and activity strategies these patients display. This can be implemented in a modern neuroscience approach by using a comprehensive pain neuroscience treatment program comprising pain neuroscience education (PNE) followed by cognition-targeted exercise therapy.13 The randomized controlled trial investigating the effectiveness of this approach is currently ongoing.7 Here we provide the detailed experimental treatment protocol of this study.

Both the practical application and positive clinical effects of PNE have been described extensively in nCSP and other chronic pain populations.36–44 PNE aims at reconceptualizing pain, by explaining that all pain is in the brain and that, rather than local tissue damage, hypersensitivity of the central nervous system may be the cause of the pain problem. PNE enables patients to understand the controversy surrounding their pain, including the lack of objective biomarkers or imaging findings.

Based on cost-effectiveness arguments,42 preference was given to the combination of a group, an online and an individual session completed with an informational leaflet to read at home, as an individual session of PNE is more effective for reducing pain and disability, but a group session is more cost-effective. General principles of PNE were explained in the group session, using examples and metaphors based on the individual experiences of the participating persons. Groups were kept small (i.e. 6 persons/group) in order to maintain an interactive and individualized approach. Between the group and individual session, the patient was asked to read an informational leaflet and to complete an online session. An example of the latter can be found at www.retrainpain.org in several languages. This online session45 covers the same information as the group session in order to facilitate deep learning and was adapted with different questions to assess the knowledge, perceptions and opinions of the patient regarding the PNE content. The information extracted from these questions was used to optimize and to individualize the third (individual) PNE session to increase its effectiveness. In addition to the educational sessions, the Neurophysiology of Pain test was used as part of the intervention to ascertain the quality of the education program by further discussing the patients’ misinterpretations upon completion of the questionnaire.46,47

As such, PNE was used to reach therapeutic alliance between the patient and his/her therapist, which is a crucial milestone in the modern neuroscience approach of nCSP. PNE includes a transfer of knowledge, which enables applying the time-contingent approach that is a critical feature of the following step (cognition-targeted exercise training). An example of the communication preparing the patient for the exercise training can be found in Box 1. Implementing this next step is essential, as PNE as a sole treatment has rather small effect sizes.38 Once the patient has adopted new beliefs and cognitions, exercise therapy with special emphasis on cognitions and perceptions (including retraining pain memories) can be applied. The patient needs to understand that the applied exercises do not intend to address local neck or back problems, but aim at ‘retraining the brain’. Therefore, it is crucial not to initiate the exercise training before therapeutic alliance regarding the nature of the patient's (spinal) pain has been reached. More information on five requirements for effective PNE in physiotherapy practice can be found elsewhere.48 Briefly, these requirements include: (1) interaction with a therapist is necessary to obtain clinically meaningful effects on pain; (2) only patients dissatisfied with their current perceptions about pain are prone to reconceptualise pain; (3) a new explanation must be intelligible to the patient; (4) any new explanation must appear plausible and beneficial to the patient; and (5) the new explanation should be shared and confirmed by the direct environment of the patient.

This step comprised two main phases: cognition-targeted motor control training and cognition-targeted dynamic and functional exercises. Both phases of this step were intertwined during treatment. Besides the willingness of the patient, there were no specific requirements to initiate a specific exercise or movement.

The main principles of “cognition-targeted” were applicable to all implemented exercises and were applied consistently.13 Detailed information can be found elsewhere,13,49 but in general these principles include the following:

• •

  All exercises should be performed in a time-contingent (“Perform this exercise 10 times, regardless of the pain”) rather than in a symptom-contingent way (“Stop or adjust the exercise when it hurts”).

• •

  Goal setting is essentially done together with the patient, focussing on functionality instead of pain relief.

• •

  The treating physical therapist should continuously assess and challenge the patients’ cognitions and perceptions about the pain and the anticipated outcome of each exercise to change maladaptive cognitions and perceptions into positive ones. Specific instructions on required communication skills are described extensively elsewhere.49

• •

  Exercises should progress towards more feared movements and activities. Fears and maladaptive perceptions on negative consequences should be discussed thoroughly.

• •

  Progression to more feared exercises can be preceded by a phase of motor imagery, provided that the perceived fear is high enough (more information in Box 2).

  Box 2.

  Patient information form on motor imagery.

  MOTOR IMAGERY

  • a.

    What?

    • Imagine the performance of a certain movement or activity in a very realistic and detailed way, without actually performing the movement or activity itself.

  • b.

    Why?

    • -

      Motor imagery can refine and facilitate actual movements. During motor imagery, the same brain areas are activated as during the performance of movements. This enables us to train the brain, without actually moving.

    • -

      This method is already used in paralyzed patients, to activate the paralyzed limbs again.

    • -

      This method is also used in (elite) sports to optimize movements and to increase the training effect.

    • -

      Motor imagery can reduce concerns regarding the actual movement or activity and can increase self-confidence.

  • c.

    How?

    • 1.

      Sit down in a comfortable position that you can maintain easily.

    • 2.

      Close your eyes and breath calmly.

    • 3.

      Imaging the performance of a certain movement, while paying attention to the following:

      • •

        The duration of the motor imagery should be equal to performing the actual movement.

      • •

        Imagine the movement or activity in detail: including the environment, the preparation of the movement or activity, … The similarity between the motor imagery and the actual movement is essential!

      • •

        Imagine the movement or activity complete and accurately.

      • •

        Maintain high focus and concentration.

    • 4.

      Keep the motor imagery session short to maintain high concentration.

This phase comprised sensorimotor control training based on the principles of Sahrmann,50 Comerford and Mottram,51 and Richardson and Jull52: these include targeting the deep cervical flexors and scapular muscles in patients with chronic neck pain, and balanced activation of the deep muscles surrounding the lumbopelvic region in patients with low back pain (e.g. multifidus, transversus abdominis, and pelvic floor muscles).

Crucial again was to use a cognition-targeted approach to comply with modern pain neuroscience. Therefore, communication regarding these exercises should be aligned with the content of the PNE. For example, the communication regarding the performance of an isolated muscle contraction of the multifidus or scapular setting is presented in Box 3.

Essential here, was the interpretation of painful signals and the theory behind the implementation of these motor control exercises. Many nCSP patients have the impression that the targeted muscles are “hurting”. Evidence indicates that these muscles display alterations in structure and/or function that may or may not be related to pain.31,53–56 However, the muscle ‘itself’ is only very rarely the actual cause of pain. Hence, these exercises were delivered with regard to the PNE content and the newly derived knowledge and perceptions. The patient was made aware that during the muscle contraction, the perceived pain is not related to the muscle itself, but rather a product of the brain and an enhanced central nociceptive processing.

In addition, the exercise program also involved teaching the patient to start moving the neck/back region on a regular basis. This was done by standardized exercises, including the pelvic tilt for chronic low back pain patients (see Fig. 1) and shoulder shrugs (see Fig. 2) or gentle movement of the neck (see Fig. 3) in chronic neck pain patients. Patients were instructed to perform this exercise every 30min during prolonged sitting or standing. Communication regarding this exercise was built upon the fact that endogenous analgesia is activated during movement, and that movement stimulates blood circulation (i.e. normal tissue physiology and metabolism). An example of this communication is presented in Box 4.

Figure 1.

Pelvic tilt. This exercise was used in chronic low back pain patients as standardized exercise to move the lower back every 30min during prolonged sitting or standing.

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Figure 2.

Shoulder shrugs. This exercise was used in chronic neck pain patients as standardized exercise to move the neck every 30min during prolonged sitting or standing.

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Figure 3.

Head swings. This exercise was used in chronic neck pain patients as standardized exercise to move the neck every 30min during prolonged sitting or standing.

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The purpose of this phase was to confront the patient with movements and activities that are feared, avoided and/or painful. Both in the physiotherapy sessions, during home exercises and in daily life it was crucial to avoid all ‘safety behaviour’ and to focus on normal and functional movements in a relaxed way (i.e. without consciously contracting specific muscles or maladaptive compensation strategies). Progression was targeted towards more complex and more feared movements and activities.

In order to detect fearful and/or painful movements and activities an ‘activity form’ was completed by the patient prior to PNE. This form asks the patient to list movements or activities of which the patient thinks they will worsen his/her complaints or disorder, and/or movements/activities that are limited due to their (spinal) pain. An example can be found in Table 1. This form enabled the therapist to detect movements or activities that needed to be addressed during therapy. In consultation with the patients, these movements and activities were sorted according to the amount of fear/pain they induce. The progression of these cognition-targeted exercises is illustrated in Box 5, using the example of bending forward in a chronic low back pain patient. The presented progression complies with what is generally seen in chronic low back pain patients. Logically, this progression was tailored to the individual patient, depending on his/her fearful movements. Other movements or activities in both chronic low back and neck pain were introduced following the same idea. Generally, the first exercises induced a similar movement as the finally intended activity, but without raising an association with the actual fearful/painful movement. Ideally, these first exercises induced some fear or stress in order to evoke a successful learning experience leading to increased confidence. For some examples of basic and advanced exercises, see Figs. 4–8.

Figure 4.

Example of a basic exercise for chronic neck pain patients: neck extension. Specific exercises should be individually-tailored and depending on the fearful movements of the patient. Communication to change inappropriate cognitions and expectations regarding the exercises is as important as providing individualized therapy.

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Figure 5.

Example of an advanced exercise for chronic neck pain patients: unstable base, patient keeps his/her head in extension while performing an arm exercise with weights. Exercises should be individually-tailored and progressing towards fearful movements. Communication to change inappropriate cognitions and expectations regarding the exercises is as important as providing individualized therapy.

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Figure 6.

Example of a basic exercise for chronic low back pain patients: exercises that induce some flexion of the back, without raising an association with the actual fearful/painful movement (e.g. bending forward). Communication to change inappropriate cognitions and expectations regarding the exercises is as important as actually performing the exercise.

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Figure 7.

Example of a basic exercise for chronic low back pain patients: exercises that induce some flexion of the back, without raising an association with the actual fearful/painful movement (e.g. bending forward). Communication to change inappropriate cognitions and expectations regarding the exercises is as important as actually performing the exercise.

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Figure 8.

Example of an advanced exercise for chronic low back pain patients: unstable base, patient performs a flexion and extension of the back with weights without ‘safety behaviour’. Exercises should be individually-tailored and progressing towards fearful movements. Communication to change inappropriate cognitions and expectations regarding the exercises is as important as providing individualized therapy.

(0.15MB).

Again, it should be acknowledged that communication on cognitions, perceptions and expectations was an essential component of cognition-targeted exercises as described above. The exercises were not used to target local aspects of the neck/back, but were rather behavioural experiments targeting the brain. Specific examples of cognition-targeted communication during exercises between the physiotherapist and a chronic pain patient are extensively described elsewhere.49

Several exercises, movements and activities used in the exercise program were also practiced at home. However, some general principles were applied:

• •

  The content, frequency and amount of home exercises should always be decided in consultation with the patient.

• •

  Home-exercises should also be applied using a time-contingent approach.

• •

  Home exercises should be implemented in a functional way (e.g. bending forward while unloading the dishwasher).

• •

  Exercises should only be performed at home when the patient is confident and secure to perform the exercise alone.

• •

  Communication for home exercises is equal important as communication during the exercises in therapy (see Box 6).

  Box 6.

  Communication regarding home exercises.

  Therapist (T): “You have been practicing this exercise very well here in therapy. How do you feel about trying it also at home?”

  Patient (P): “I feel confident.”

  T: “Great! Here you performed 10 repetitions; I propose to do the same at home. Are you ok with that?”

  P: “Yes.”

  T: “Perfect. Imagine, you are at home, doing this exercise and during the 6threpetition, you suddenly feel a pang in the neck/back. What will you do?”

  P: “I stop the exercise and try it again later?”

  T: “Everything depends on the value and explanation you give to this pang. When it occurs, does it mean that something is wrong in your neck/back?”

  P: “Right, the pain I feel in my neck/back is an unreliable signal and I should continue performing the exercise.”

  T: “Indeed, and do not forget that you have been performing the exercise excellent during the therapy here, this should give you a lot of confidence to perform it at home.”