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Physiotherapy Theory and PracticeAn International Journal of Physical Therapy

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: http://www.tandfonline.com/loi/iptp20

Combining manual therapy with painneuroscience education in the treatment ofchronic low back pain: A narrative review of theliterature

Emilio J. Puentedura PT, DPT, PhD & Timothy Flynn PT, PhD

To cite this article: Emilio J. Puentedura PT, DPT, PhD & Timothy Flynn PT, PhD (2016)Combining manual therapy with pain neuroscience education in the treatment of chroniclow back pain: A narrative review of the literature, Physiotherapy Theory and Practice, 32:5,408-414, DOI: 10.1080/09593985.2016.1194663

To link to this article: http://dx.doi.org/10.1080/09593985.2016.1194663

Published online: 30 Jun 2016.

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PERSPECTIVE

Combining manual therapy with pain neuroscience education in the treatmentof chronic low back pain: A narrative review of the literatureEmilio J. Puentedura, PT, DPT, PhDa, and Timothy Flynn, PT, PhDb

aDepartment of Physical Therapy, University of Nevada, Las Vegas, Las Vegas, NV, USA; bSchool of Physical Therapy, South College, Knoxville, TN, USA

ABSTRACTTeaching people with chronic low back pain (CLBP) about the neurobiology and neurophysiology oftheir pain is referred to as pain neuroscience education (PNE). There is growing evidence that whenPNE is provided to patients with chronic musculoskeletal pain, it can result in decreased pain, paincatastrophization, disability, and improved physical performance. Because the aim of PNE is to shiftthe patient’s focus from the tissues in the low back as the source of their pain to the brain’sinterpretation of inputs, many clinicians could mistakenly believe that PNE should be a “hands-off,”education-only approach. An argument can be made that by providing manual therapy or exercise toaddress local tissue pathology, the patient’s focus could be brought back to the low back tissues asthe source of their problem. In this narrative literature review, we present the case for a balancedapproach that combines PNE with manual therapy and exercise by considering how manual therapycan also be incorporated for interventions with patients with CLBP. We propose that as well asproducing local mechanical effects, providing manual therapy within a PNE context can be seen asmeeting or perhaps enhancing patient expectations, and also refreshing or sharpening body schemamaps within the brain. Ideally, all of this should lead to better outcomes in patients with CLBP.

ARTICLE HISTORYReceived 12 November 2015Revised 28 January 2016Accepted 5 May 2016

KEYWORDSBody schema; exercise;manual therapy;neuroscience; pain; patientexpectations

Introduction

According to a report from the Institute of Medicine,the financial toll of chronic pain, of which chronic lowback pain (CLBP) is the leading condition, is estimatedto cost between $365 and $560 billion per year(Committee on Advancing Pain Research, Care andEducation, 2011). CLBP is a highly prevalent condition,which imposes an enormous economic burden ontoday’s society. The suffering associated with CLBPcan reduce a person’s quality of life and lead to long-term disability, absenteeism from work, and excessivehealthcare utilization (Gore et al, 2012; Ibrahim,Tleyjeh, and Gabbar 2008; Melloh et al, 2008).

The first clinical practice guideline for the managementof low back pain was published in 1987 by theQuebec TaskForce (Spitzer, 1987). Since then, there has been exponen-tial growth in research in this area, with over 2500 clinicaltrials and more than 32 systematic reviews evaluatinginterventions for low back pain reported in the Cochranedatabase (Koes et al, 2010). A review of the latest clinicalpractice guidelines for CLBP finds consistent recommen-dations for supervised exercises, cognitive behavioral ther-apy and multidisciplinary treatment, but shows somediscrepancies for recommendations regarding spinal

manipulation (manual therapy) and drug treatment(Delitto et al, 2012; Koes et al, 2010).

A relatively new and promising approach in themanagement of CLBP has focused on teaching peopleabout the neurobiology and neurophysiology of pain,which is referred to as pain neuroscience education(PNE) (Butler and Moseley, 2013; Louw, Diener,Butler, and Puentedura, 2011; Puentedura and Louw,2012). Several randomized controlled trials and tworecent systematic reviews have reported favorable out-comes following PNE in patients with chronic pain interms of reduced pain, pain catastrophization, disability,and improved physical performance (Clarke, Ryan, andMartin, 2011; Louw, Diener, Butler, and Puentedura,2011; Moseley, 2002; Moseley, 2003a; Moseley, 2003b;Moseley, Nicholas, and Hodges, 2004). The focus of PNEis reconceptualization of pain by teaching patients moreabout the neurobiological and neurophysiological pro-cesses involved with their pain experiences versus focus-ing solely on tissue pathology. In the patient with CLBP,this pain reconceptualization attempts to help themunderstand that pain and tissue injury are differentconstructs (Moseley, 2004a, Moseley, 2005; Moseley,Nicholas, and Hodges, 2004).

CONTACT Emilio J. Puentedura, PT, DPT, PhD Louie.Puentedura@unlv.edu Department of Physical Therapy, University of Nevada, Las Vegas, 4505 S.Maryland Parkway, Box 453029, Las Vegas, NV 89514-3029, USA.Color versions of one or more of the figures in this article can be found online at www.tandfonline.com/iptp.

PHYSIOTHERAPY THEORY AND PRACTICE2016, VOL. 32, NO. 5, 408–414http://dx.doi.org/10.1080/09593985.2016.1194663

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Through their training and education, most manualtherapy clinicians are educated in the biomedical modelof pain (Kaltenborn and Lindahl, 1969; Maitland, 1973;Nijs et al, 2013). Underlying this traditional model of painis the assumption that there is a direct link between theamount of local tissue damage and the pain experiencedby the patient (Haldeman, 1990). Following this biome-dical model, manual therapy clinicians might concludethat addressing the underlying pathology (presumed bio-mechanical fault) should result in a reduction of symp-toms and subsequent recovery of normal function by thepatient. In the case of acute low back pain, where noci-ception from tissues in the low back is the dominant painmechanism, this approach seems appropriate and hasbeen shown to provide significant benefit when providedearly in the course of care (Childs et al, 2015; Fritz et al,2015; Rhon and Fritz, 2015). However, in the case ofCLBP, there is often little to no adherence to this biome-dical model of pain, and the local application of manualtherapy alone is rarely followed by any lasting reductionin symptoms and improvement in function (Delitto et al,2012; Gore et al, 2012; Rubinstein et al, 2011).

Manual therapists may therefore be left with a con-undrum when treating patients with CLBP. Currentevidence suggests that PNE can be effective, with theobjective being to deemphasize the tissues of the lowback as the dominant source of the problem and empha-size a deeper understanding of the pain experience as themeans to eventual recovery (Clarke, Ryan, and Martin,2011; Louw, Diener, Butler, and Puentedura, 2011). Onthe surface, this might suggest a “hands-off” approach totherapeutic interventions. An extension of this argumentis that any application of manual therapy interventionsto the low back would re-focus the patient on theirtissues (back) as the source of their chronic pain, andthereby undo any progress expected with PNE and exer-cise/activity. This “hands-off” approach may be seen as“swinging the pendulum” too far from the biomedicalmodel of pain (Jull and Moore, 2012).

The objective of this narrative is to review the literaturesupporting the inclusion of manual therapies in the ther-apeutic management of CLBP by re-thinking the value of“hands-on” interventions in combination with PNE andsupervised exercise. We propose the need to balance PNEwith manual therapy in the treatment of CLBP to meetpatient expectations and beliefs which may enhance thetreatment with an improved brain body schema.

How does manual therapy work?

Manual therapy can be defined as the provision ofmobilization/manipulation techniques to address mus-culoskeletal pain and dysfunction (American Physical

Therapy Association, 2004). The American PhysicalTherapy Association (APTA) defines manual therapytechniques as “skilled hand movements and skilledpassive movements of joints and soft tissue and areintended to improve tissue extensibility; increaserange of motion; induce relaxation; mobilize or manip-ulate soft tissue and joints; modulate pain; and reducesoft tissue swelling, inflammation, or restriction”(American Physical Therapy Association, 2014).Prevailing thoughts on the mechanisms of manual ther-apy propose a mix of three mechanisms—biomechani-cal, neurophysiological, and/or placebo effects (Bialoskyet al, 2009; Bialosky, Bishop, George, and Robinson,2011; Bishop, Bialosky, and Cleland, 2011). It is sug-gested that a transient, mechanical stimulus (spinalmanipulation) may create a chain of local biomechani-cal effects and neurophysiological effects mediatedthrough the peripheral nervous system, spinal cord,and higher centers. Traditionally, manual therapy inter-ventions are thought to be dependent upon bottom-up-mediated factors like stimulus intensity, but in recentyears greater attention has been drawn to top-down-mediated factors like the patient’s expectations(Gifford, 2013; Tiemann et al, 2015).

If we take the case of a patient with low back painreceiving a manual therapy intervention to their lumbarspine, the mechanical stimulus is theorized to causemovement at the spinal motion segments, which mayimprove segmental motion, decrease local tissue inflam-matory factors, and facilitate local muscular control(Colloca et al, 2006; Hsieh et al, 1995; Teodorczyk-Injeyan, Injeyan, and Ruegg, 2006). Providing jointmobilization to the lumbar spine can be viewed as a“bottom-up” approach because the therapist can besaid to be providing input into the nervous system inorder to change output from the brain (i.e., pain). Inother words, the therapist’s intent is to decrease noci-ceptive input into the system and thereby modulate thepain experience. But we should also consider the “top-down” effects, i.e., the brain and its integral role inproducing a pain experience (Figure 1).

There is very little evidence that manual therapyperformed under anesthesia is effective for CLBP(Digiorgi, 2013; Gordon, Cremata, and Hawk, 2014)and perhaps this is because we need to “manipulate”the brain, and not just the joints and other peripheraltissues, to bring about a change in the pain experience.Traditional thoughts about the mechanisms underlyingmanual therapy have alluded to the gate control theoryof pain (Nathan, 1976), whereby one sensory modality(joint mobilization) can modulate another (back pain).Additionally, the provision of rhythmic oscillations tolumbar motion segments in varying grades of depth can

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also be seen as graded exposure; however, these con-cepts fail to consider the importance of the patient’sbrain’s interpretation of the input and the changes thatmight be induced through the input of manual therapy.

Manipulating the brain

Enhancing patient expectations

There is ample evidence linking patients’ expectancies forrecovery and health outcomes (Auer et al, 2016; Iles,Davidson, Taylor, and O’Halloran, 2009). A patient thatexpects a particular treatment will help their pain is morelikely to experience improvement than a patient with lowerexpectations (Bishop, Bialosky, and Cleland, 2011;Puentedura et al, 2012). The positive expectation of benefitfrom a particular treatment intervention is often termedthe placebo effect or placebo response (Benedetti, 2013;Bialosky, Bishop, George, and Robinson, 2011). A morenuanced view of placebo is that it represents the limit pointof our current understanding of the mechanisms behindthe observed treatment effect. Thus, many factors maycontribute to the placebo response, such as the patient–therapist relationship, the patient’s expectations and needs,the patient’s personality and psychological state, the sever-ity and discomfort of the symptoms, the type of verbalinstructions, the treatment preparation characteristics, andthe clinical environmental milieu (Ross and Buckalew,1985). This suggests that whenever a treatment is given toa patient, it is not done so in a vacuum, but in a complex setof psychological states that vary from patient to patient andfrom situation to situation (Benedetti and Amanzio, 2013).That is, “placebo” treatment is not necessarily “no treat-ment” or a true control.

When manual therapy is provided to a patient withCLBP, it is administered along with a complex set ofphysical and psychological stimuli (including, but notlimited to tactile, verbal and non-verbal cues) whichimply to the patient that a clinical improvement shouldbe occurring shortly. These physical and psychosocialstimuli represent the context around the therapy andthe patient, and such a context may be as important asthe specific effect of the intervention. The contextualfactors that might affect the therapeutic outcome can berepresented by the characteristics of the treatment (handcontact, direction of movement, force), the patient’s andtherapist’s characteristics (treatment and pain beliefs, sta-tus, gender), the patient–provider relationship (sugges-tion, reassurance, and compassion), and the healthcaresetting (clinic and room layout) (Di Blasi et al, 2001).

An argument could be made that when a patientwith CLBP consults a manual therapist, they wouldexpect their painful area (back) to be touched/pal-pated/treated. Adopting a “hands off” PNE approachmay not necessarily meet those expectations and couldarguably induce a nocebo effect, thereby inducing nega-tive expectations and negative outcomes (Benedetti,2013). Do expert manual therapists enhance the posi-tive recovery expectations of their patients, either con-sciously or not? A study which examined thecharacteristics of 12 therapists who were classified aseither “expert” or “average,” based on the outcomes oftheir patients, found that the “expert” therapists wherenot distinguished by years of experience (Resnik andJensen, 2003). Instead, “expert” therapists had apatient-centered approach to care, characterized bycollaborative clinical reasoning and promotion ofpatient empowerment (Resnik and Hart, 2003; Resnik

Figure 1. Bottom-up-mediated factors (left) involve application of manual therapy interventions to the tissues in the context of theenvironment, whereas top-down-mediated factors (right) involve the patient’s thoughts, beliefs, and expectations (cognitions) abouttheir pain experience and the therapy interventions provided.

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and Jensen, 2003). In other words, they showed theyreally cared about their patients; they listened to them,they empathized, and they worked with them to achievegoals set by their patients. Expert manual therapistsdemonstrate confidence in their manual skills andwhen observed performing manual therapy, they arewell-balanced, smooth in their movements, quick tolocalize treatment levels, and gentle in their deliveryof manual therapy techniques (Edwards et al, 2004;Hartman, 2014; Resnik and Hart, 2003; Wainwright,Shepard, Harman, and Stephens, 2011).

Somatosensory cortex—manual therapy as ameans to refresh body schema maps

There are many terms that define how the brain recog-nizes the self as “self.” These include body schema,image, identity, ownership, awareness, self-perception,etc. (Holmes and Spence, 2004; Makin, Holmes, andEhrsson, 2008), and these terms are often used in dis-tinct ways by different disciplines. Neurologist SirHenry Head (1861–1940) conducted pioneering workinto the somatosensory system (Head, 1920) andcoined the term “body schema” as the brain’s dynamicrepresentation of the body which is sculpted by exter-oceptive and interoceptive experiences. But it wasWilder Penfield (1891–1976) who is credited withestablishing the “map” of the human body (homuncu-lus) in the sensory and motor cortices (Penfield andRasmussen, 1950). Current evidence suggests that theserepresentational body maps are dynamically main-tained in the brain (e.g., neuroplasticity) and are nega-tively influenced by neglect, decreased movement, andpain (Maihöfner, Handwerker, Neundörfer, andBirklein, 2003).

Recent research has shown that people withchronic pain demonstrate impairments in lateralityjudgements (identifying a body part as being orientedto the left or right), which is considered dependenton an intact body schema in the sensorimotor areasof the cortex (Bowering, Butler, Fulton, and Moseley,2014; Bray and Moseley, 2011; Elsig et al, 2014;Moseley, 2004b). Furthermore, body image is dis-rupted, and tactile acuity is decreased in the area ofusual pain in patients with CLBP (Moseley, 2008).This phenomenon has been referred to as “smudging”of the sensorimotor homunculus (Louw andPuentedura, 2013), and it is thought that retraininglaterality and tactile discrimination can “sharpen” or“refocus” the homunculus and lead to decreased pain(Moseley and Wiech, 2009; Moseley, Zalucki, andWiech, 2008) (Figure 2).

Getting patients with CLBP to make judgmentsabout which direction a trunk is facing in multipleimages, and having them localize light touch sensationsin discrete sections of their low back can be seen as a“top-down” approach. An argument could also bemade that the skillful delivery of manual therapy tothe low back motion segments, as long as they do notevoke a pain response, can assist in re-establishingtactile discrimination (e.g., assist in “localization” ofthe spinal motion segment) and thereby “sharpen” or“refocus” the homunculus related to the low back.Consider that the skillful delivery of manual therapyinvolves constant communication between the patientand therapist—“how does this feel here?”; “this is yourL4 spinous process”; “what if I push it this way?”; “howabout here at L5?”. It could be argued that the applica-tion of manual therapy in such a manner could linksensory and proprioceptive neural circuits within thebrain and help to refresh its representational bodymaps.

In a recent case series (Louw et al, 2015), researchersreported that a brief tactile intervention associated withbrain remapping resulted in immediate improvements inpain and spinal flexion range in 16 patients with CLBP.Patients were shown a picture of the homunculus andtold that it was a map of their body’s representation inthe brain. They were also taught that when persistentpain is present, the map can become “less sharp” asthose body parts are moved and used less, and thatsharpening or refocusing the map could reduce theirpain. By touching the back in various areas and sharpen-ing their attention to where they were being touchedwith a pen, the therapy would aim to “sharpen” the map.They used a 9-block grid and randomly stimulated the 9-blocks while asking for continuous feedback as to thelocalization of the stimulus (Figure 3) and found thatmean pain rating (0–10 scale) decreased by 1.91 (range0–6) and forward flexion improved by a mean of4.82 cm (range –1 to 21). The study demonstrated thatan intervention “devoid of physical movement and asso-ciated with cortical reorganization” (Louw et al, 2015)could decrease pain and cause an immediate increase inlumbar flexion range in patients with CLBP.

Emerging evidence suggests coupling PNE andmovement therapies

Finally, the systematic review of the efficacy of PNE forpain, function, disability, psychosocial factors, move-ment, and healthcare utilization in individuals withchronic musculoskeletal pain was recently updated(Louw, Zimney, Puentedura, and Diener, 2016). Intheir review of 13 studies, the authors found five were

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education-only approaches, whereas the remainingeight combined PNE with a movement-based strategysuch as exercise/activity and/or manual therapy.Outcomes appeared to favor the combination of PNEwith movement, either passive (manual therapy) and/oractive, suggesting that “hands-on” approaches resultedin more favorable responses.

Conclusion

There is growing evidence that PNE can be effective inthe management of chronic musculoskeletal pain. Theemphasis of PNE is to have patients reconceptualizetheir pain and to understand that pain and tissue injuryare different constructs. It may, therefore, seem coun-terintuitive to include an intervention such as manualtherapy along with PNE, as it would appear to beaddressing a presumed tissue problem. This narrativereview makes the case for a balanced approach in thetherapeutic management of chronic musculoskeletalpain by re-thinking the value of “hands-on” interven-tions in combination with PNE and supervised exer-cise/movement activities. Finally, an updated systematicreview of randomized controlled trials of PNE suggeststhat an education-only approach is not as effective asthose that combined pain education with manual ther-apy and supervised exercise.

Declaration of interest

Authors report no conflict of interest. The authors aloneare responsible for the content and writing of the paper.

Figure 2. The intact body schema in the sensorimotor cortex is dynamically maintained and it is postulated that areas of the bodyimage can be disrupted, leading to “smudging” or the body image in the brain becoming “out of focus.” In the top image, thesmudging of the cortical region associated with the lower back is thought to lead to decreased tactile acuity and body awareness,and perhaps persistent low back pain. The lower image shows the intact (sharp or “in focus”) body schema, where tactile acuity andbody awareness are not compromised and, hence, pain may not be an issue.

Figure 3. 9-Block localization treatment grid used in the caseseries by Louw et al. (2015).

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