Highlights
- •Patients with chronic low back pain (cLBP) show higher blood oxygen level–dependent signal when observing physical exercises.
- •Spinal manipulative therapy (SMT) reduces clinical pain, expected pain, and fear of movement in cLBP.
- •SMT manipulation and mobilization equally improve clinical outcomes.
- •SMT reduces brain responses to observing back-straining exercises in cLBP.
Abstract
Heightened anticipation and fear of movement-related pain has been linked to detrimental
fear-avoidance behavior in chronic low back pain (cLBP). Spinal manipulative therapy
(SMT) has been proposed to work partly by exposing patients to nonharmful but forceful
mobilization of the painful joint, thereby disrupting the relationship among pain
anticipation, fear, and movement. Here, we investigated the brain processes underpinning
pain anticipation and fear of movement in cLBP, and their modulation by SMT, using
functional magnetic resonance imaging. Fifteen cLBP patients and 16 healthy control
(HC) subjects were scanned while observing and rating video clips depicting back-straining
or neutral physical exercises, which they knew they would have to perform at the end
of the visit. This task was repeated after a single session of spinal manipulation
(cLBP and HC group) or mobilization (cLBP group only), in separate visits. Compared
with HC subjects, cLBP patients reported higher expected pain and fear of performing
the observed exercises. These ratings, along with clinical pain, were reduced by SMT.
Moreover, cLBP, relative to HC subjects, demonstrated higher blood oxygen level–dependent
signal in brain circuitry that has previously been implicated in salience, social
cognition, and mentalizing, while observing back straining compared with neutral exercises.
The engagement of this circuitry was reduced after SMT, and especially the spinal
manipulation session, proportionally to the magnitude of SMT-induced reduction in
anticipated pain and fear. This study sheds light on the brain processing of anticipated
pain and fear of back-straining movement in cLBP, and suggests that SMT may reduce
cognitive and affective-motivational aspects of fear-avoidance behavior, along with
corresponding brain processes.
Perspective
This study of cLBP patients investigated how SMT affects clinical pain, expected pain,
and fear of physical exercises. The results indicate that one of the mechanisms of
SMT may be to reduce pain expectancy, fear of movement, and associated brain responses.
Key words
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Article info
Publication history
Published online: July 03, 2018
Accepted:
May 28,
2018
Received in revised form:
May 16,
2018
Received:
March 12,
2018
Footnotes
Supported by the NCMIC foundation (to M.L.L.), Norwegian Research Council/Marie Sklodowska-Curie Actions (FRICON/COFUND-240553/F20) (to D.M.E.), National Center for Research Resources (P41RR14075; CRC 1 UL1 RR025758), Harvard Clinical and Translational Science Center, Martinos Computing facilities, and National Institutes of Health (Grant Nos. S10RR023401, S10RR019307, S10RR019254, and S10RR023043).
The authors have no conflicts of interest to declare.
Identification
Copyright
© 2018 by the American Pain Society
