Additional effect of pain neuroscience education to neuromuscular exercise in chronic low back pain: a randomized controlled trial

Pain Neuroscience Education (PNE) and Neuromuscular Exercise (NME) are commonly used in chronic low back pain (CLBP) rehabilitation. However, evidence remains limited and inconsistent regarding whether adding PNE to exercise provides incremental benefits beyond exercise alone across pain, disability, and psychosocial outcomes. To determine whether adding PNE to a structured NME program provides additional improvements in pain intensity, disability, and psychological outcomes compared with NME alone in individuals with CLBP. A single-blind, two-arm randomized controlled trial was conducted in Iran involving 60 adults with CLBP. Participants were randomized to either PNE (10–20 min/session, three times weekly for eight weeks, delivered immediately before exercise using verbal, visual and interactive methods) followed by NME (experimental group) or NME alone (control group). Both groups attended supervised sessions three times per week for eight weeks. The primary outcome was pain intensity (VAS). Secondary outcomes included disability (ODI), fear-avoidance beliefs (FABQ), pain self-efficacy (PSEQ), and kinesiophobia (TSK). Outcomes were assessed at baseline, post-intervention, and six-month follow-up. Sample size was determined a priori based on the primary outcome. Data were analyzed using repeated-measures ANOVA with intention-to-treat principle, with Greenhouse–Geisser correction when required. Pain intensity and disability showed no significant Group × Time interactions (VAS: p = 0.13, \({η}ₚ²\) = 0.04; ODI: p = 0.11, \({η}ₚ²\) = 0.05), and mean changes did not reach minimal clinically important difference (MCID) thresholds. Significant Group × Time interactions were observed for FABQ ( p < 0.001, \({η}ₚ²\) = 0.16), PSEQ ( p < 0.001, \({η}ₚ²\) = 0.21), and TSK ( p < 0.001, \({η}ₚ²\) = 0.15). However, only the reduction in kinesiophobia exceeded the published MCID, whereas improvements in the other psychosocial outcomes did not reach established thresholds for clinical relevance. Adding PNE to a structured NME program did not provide additional benefits for pain intensity or disability compared with NME alone. Although the combined intervention was associated with statistically significant improvements in several psychosocial outcomes, clinically meaningful benefit was demonstrated only for kinesiophobia. These psychosocial findings should therefore be interpreted cautiously, considering that they were secondary outcomes and that the trial was powered for the primary outcome. PNE may represent a useful adjunct to exercise-based rehabilitation when targeting movement-related fear. Trial Registration: IRCT20190427043384N2 (registered on 17 March 2023).