Pain resilience therapy vs. pain neuroscience education for adults with chronic low back pain: a pragmatic randomized controlled trial

Background Low back pain has a lifetime prevalence approaching 80%, with approximately 20% of cases becoming chronic (CLBP). Interventions typically target vulnerability factors, while protective factors such as pain resilience remain under-researched.Methods In this pragmatic, parallel-group, superiority randomised controlled trial, 72 adults with CLBP ≥6 months were randomised 1:1 to Pain Resilience Therapy (PRT) or Pain Neuroscience Education (PNE). Participants received eight individual 60-minute telehealth sessions, twice weekly over 4 weeks, from one physical therapist. The primary outcome was pain intensity (Defense and Veterans Pain Rating Scale [DVPRS]) at 90 days. Secondary outcomes included pain interference (DVPRS; PROMIS® 6b) and pain resilience (Pain Resilience Scale). ANCOVA was adjusted for baseline with Holm–Bonferroni correction.Results Sixty participants (83%) completed follow-up. At 90 days, adjusted mean pain intensity was 1.94 with PRT versus 4.69 with PNE (difference 2.75; 95% CI 2.00–3.50; p<.001; Hedges’ g = 1.93). A ≥ 50% pain reduction occurred in 93.3% of PRT versus 23.3% of PNE. PRT’s NNT = 2. Pain resilience increased by 34% with PRT and declined by 9% with PNE (difference 10.24; g = 1.39). PRT was superior on PROMIS® 6b (3.95; g = 0.97) and DVPRS for activity, mood, and stress interference (g = 0.71–0.88), but not sleep (p=.061). Pain intensity and resilience remained robust after intention-to-treat analyses. No adverse events occurred.Conclusion PRT produced greater reductions in pain intensity and improvements in pain interference and resilience than PNE in adults with CLBP. This single-center, single-therapist trial with 90-day follow-up warrants larger, multisite studies with longer follow-up.Trial registration: ClinicalTrials.gov #NCT06971809.