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New back pain treatment targets nervous system

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Brain training works for pain and disability

People suffering chronic back pain have been given hope with a new treatment that focuses on retraining how the back and the brain communicate.

A paper out today in in the Journal of the American Medical Association reveals results from a study by Brunel University London, The University of New South Wales and others across Australia and Europe.

Researchers compared 138 chronic lower back pain patients who took a 12-week sensorimotor training course, with 138 put on a 12-week course of sham treatments.

“These results show real promise,” said Dr Neil O’Connell at Brunel University London.

“Our trial used a carefully designed sham control group so we can be confident that the benefits we observed were the result of this novel treatment approach. The next challenge is to see if the benefits that we have found are seen more widely.”

Sensorimotor retraining switches how people think about their body in pain, how they process sensory information from their back and how they move their back during activities.

People with chronic back pain should be able to have the treatment from trained physiotherapists, exercise physiologists and other clinicians, they hope in the next six to nine months.

"What we observed in our trial was a clinically meaningful effect on pain intensity and a clinically meaningful effect on disability,” said Professor James McAuley from UNSW.

“People were happier, they reported their backs felt better and their quality of life was better. 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.”

The new treatment challenges traditional treatments for chronic back pain, such as drugs and treatments that focus on the back such as spinal manipulation, injections, surgery and spinal cord stimulators, by viewing long-standing back pain as a modifiable problem of the nervous system rather than a disc, bone or muscle problem.

"If you compare the results to studies looking at opioid treatment versus placebo, the difference for that is less than one point out of 10 in pain intensity, it’s only short term and there is little improvement in disability. We see similar results for studies comparing manual therapy to sham or exercise to sham," Prof. McAuley said.

"This is the first new treatment of its kind for back pain – which has been the number one cause of the Global Disability Burden for the last 30 years – that has been tested against placebo."

The treatment is based on research that showed the nervous system of people suffering from chronic back pain behaves in a different way from people who have a recent injury to the lower back.

People with back pain are often told their back is vulnerable and needs protecting, Prof McAuley said. “This changes how we filter and interpret information from our back and how we move our back. 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,” he said.

“This treatment includes specially designed education modules and methods and sensorimotor retraining,” said Professor Lorimer Moseley at the University of South Australia.

“This aims to correct the dysfunction we now know is involved in most chronic back pain and that’s a disruption within the nervous system. The disruption results in two problems: a hypersensitive pain system and imprecise communication between the back and the brain.”

The treatment aims to achieve three goals. The first is to align patient understanding with the latest scientific understanding about what causes chronic back pain. The second is to normalise the way the back and the brain communicate with each other, and thirdly, to gradually retrain the body and the brain back to a normal protection setting and a resumption of usual activities.

Traditional therapies concentrate on fixing something in your back, injecting a disc, loosening up the joints or strengthening the muscles. What makes sensorimotor retraining different, according to Prof McAuley is that it looks at the whole system – what people think about their back, how the back and brain communicate, how the back is moved, as well as the fitness of the back.