Appraising Efficacy of Cognitive Pain Management Strategies for the Rehabilitation of Non-Chronic Sciatica: A Randomized Control Trial

Introduction

Low back ache (LBA) is a heterogeneous disorder involving patients with dominant nociceptive (e.g., myofascial), neuropathic, and central sensitization pain.¹

In Bharat, approximately 60% of people experience LBA at least once in their lifetime.² However, more than 69% of these individuals will have a recurrence of symptoms within a year of recovering from LBA.³ Due to this high recurrence rate, LBA has become the fourth leading cause of disability worldwide, following ischemic heart disease, cerebrovascular pathologies, and lower respiratory tract infections.^4-5 In developing nations like Bharat, factors such as low socioeconomic status, low education levels, physical factors like repetitive heavy lifting, prolonged static or awkward postures, and psychosocial factors like anxiety, mood depression, job dissatisfaction, mental stress, irregular work periods, and obesity are closely linked to LBA.^2,6 Nerve root compression associated with LBA can cause pain radiating into the lower extremities in a dermatomal pattern, often accompanied by tingling, numbness, paresthesia, and occasionally shooting pain. The most commonly used clinical test for this is the ‘Lasegue test’, also known as the ‘Straight Leg Raise Test’ (Figure 1).

The increasing number of chronic sciatica cases in society drew the author's attention to the lack of effective early management strategies, leading to more chronic or post-operative cases. Non-chronic sciatica cases have often been overlooked, with the assumption that they are self-limiting. Therefore, the author decided to focus on this specific, often neglected area non-chronic sciatica with the positive intention of contributing to society by identifying potential treatments to address the problem before it worsens and becomes chronic. To achieve this, the author gathered insights from physiotherapists across Bharat through an online closed-ended questionnaire. The conclusion was that the lack of a Bio-Psycho-Social (BPS) approach in clinical practice might be a barrier to optimal recovery.⁷

The neuromatrix theory of pain, introduced by Canadian psychologist Ronald Melzack in the late 1980s as an extension of the gate control theory, suggests that pain can be generated by the activation of the neural network even in the absence of sensory input from injury or inflammation. Various factors, as shown in Figure 2, can activate pain, and addressing all these factors is crucial for optimal pain management. This can be achieved by utilizing cognitive pain management strategies.

Hypothesis

Null Hypothesis (Ho)

There is no statistically significant difference between the efficacy of cognitive pain management strategies combined with conventional physical therapy and conventional physical therapy alone, on pain in non-chronic sciatica.

Alternative Hypothesis (H1)

There is a statistically significant difference between the efficacy of cognitive pain management strategies combined with conventional physical therapy and conventional physical therapy alone, on pain in non-chronic sciatica.

Materials and Methods

This was a single-blind randomized control trial where the subjects were blinded to their study group allocation. The primary investigator was not blinded and therefore was not involved in outcome assessment or sampling.

Inclusion Criteria

• Age: 40-60 years
• Gender: All
• Subjects with a basic understanding of English
• Subjects with at least a minimum of graduation level of education
• LBA with pain and/or numbness radiating below the knee for less than 12 weeks
• Presence of one or more of the following radicular signs:⁸

1. Sensory loss/paresthesia in any of the L4 to S1 dermatomes

2. Diminished Patellar/Achilles reflex

3. Muscle strength deficit in any of the L4-S1 myotomes

4. Positive Lasegue sign

5. Referred/diagnosed cases were also tested against inclusion/exclusion criteria before enrollment.

 No specific inclusion criteria were set for the application of cognitive pain management strategies (CPMx) since sciatica is often associated with anxiety, depression, anger, fear of chronic pain, and avoidance behaviors. These negative constructs can play a major role in the transition to chronic sciatica.⁹ Psycho-social factors are also associated with the occurrence of LBA.^10,11 Purely biological interventions may not suffice, and these factors need to be addressed with psycho-social methods as well.

Patients were allowed to take prescribed pain medications (Aceclofenac 100 mg + Paracetamol 325 mg twice a day after meals, and Pregabalin 75 mg once a day before bed) as recommended by registered medical practitioners.

Exclusion Criteria

• Presence of red flags like cauda equina syndrome
• Positive Cross Leg Straight Leg Raise Test (SLRT)
• Bilateral radiculopathy
• Centralization of pain during flexion movements
• Recent physiotherapy / naturopathy / acupuncture other treatments for the present condition
• Ongoing medications such as steroids or opioids
• Previous surgical history related to the spine or pelvic girdle
• Previous history of LBA associated with radiculopathy
• Presence of any declared medical conditions like acute infections, systemic disorders, or psychiatric conditions
• Patients unwilling to participate in the study

The procedure was thoroughly explained to the screened and selected patients and were asked to sign a consent form before enrolling in the study. Once enrolled, patients were randomly allocated to either a control group or an experimental group using a serial sampling technique. A total of 30 subjects were included in the pilot study, divided into two equal groups of 15 subjects each. Demographic homogeneity was maintained, and pre- and post-intervention data were collected for all the participants. The McGill Pain Questionnaire (SF-MPQ-2) was used as the primary outcome measure.

Timepoints

• Baseline: Day one
• Post-intervention: End of two weeks

 Intervention

Experimental/Interventional Group

The experimental group received cognitive pain management (CPMx) strategies combined with conventional physiotherapy, including Directional Preference Exercises (DPE), therapeutic ultrasound, and transcutaneous electrical nerve stimulation (TENS), following a two week protocol - five days a week for a total of 10 visits.

Control Group

The control group received general non-specific counseling and conventional physical therapy, including DPE, therapeutic ultrasound, and TENS, following the same two-week protocol - five days a week for a total of 10 visits.

Electrotherapy and exercise therapy treatments were administered by a team of qualified physical therapists under the supervision of the primary researcher. All team members were instructed to adhere strictly to the prescribed treatment and maintain confidentiality regarding patients' treatment groups. The primary research investigator conducted counseling for both the groups. All data derived from questionnaires were compiled in a Microsoft Excel datasheet for statistical analysis.

Ethical considerations, including approval from the ethics committee and informed consent were taken.

Results

There was no significant difference between the mean baseline SF-MPQ-2 scores of the experimental group (M = 151.8) and the control group (M = 152.8). The mean difference for the experimental group was M = 102.6, and for the control group, it was M = 54.33. The t-value was 3.70557, and the P-value was 0.00092, indicating a significant result at P <0.05.

Data analysis rejected the null hypothesis and confirmed the alternative hypothesis, showing a statistically significant difference between the efficacy of CPMx strategies combined with conventional physical therapy and conventional physical therapy alone, in reducing pain in non-chronic sciatica. The study thus achieved its objective of testing the utility of CPMx strategies alongside conventional physical therapy and found that the experimental protocol was superior in terms of pain reduction.

Discussion

The superior results observed in the experimental group, treated with cognitive pain management (CPMx) strategies combined with conventional physical therapy, can be attributed to several key mechanisms that underpin the biopsychosocial (BPS) model of pain management. The BPS model emphasizes that pain is not purely a physical phenomenon but is influenced by a complex interaction of biological, psychological, and social factors.¹² (Figure 3)

Minimizing Catastrophizing Effects

Catastrophizing is a cognitive distortion where patients experience an exaggerated negative orientation towards pain stimuli, often leading to increased pain perception and emotional distress. The neuromatrix theory of pain, as introduced by Melzack, supports the idea that pain is a multidimensional experience influenced by various sensory, cognitive, and emotional inputs. The cognitive interventions used in CPMx strategies are designed to directly target these cognitive distortions, thereby reducing the impact of catastrophizing. This is crucial because research has shown that pain catastrophizing is a significant predictor of chronic pain development, particularly in conditions like sciatica.¹³

By addressing these negative cognitive patterns early, the experimental protocol may prevent the transition from acute to chronic pain, offering a significant advantage over conventional physical therapy alone.¹⁴

Neuroplasticity and Pain Modulation

The brain's ability to adapt and reorganize itself, known as neuroplasticity, plays a critical role in pain perception. Chronic pain conditions, including sciatica, are often associated with maladaptive neuroplastic changes, where the central nervous system becomes hyper-responsive to pain signals. Cognitive pain management strategies, including cognitive-behavioral therapy (CBT) techniques, mindfulness, and relaxation exercises, aim to reverse these maladaptive changes. By promoting positive neuroplasticity, these strategies can help 'retrain' the brain to interpret pain signals differently, leading to a reduction in pain intensity and improved functional outcomes.¹⁵

Influence of Psychosocial Factors

Psychosocial factors such as anxiety, depression, and social support are known to significantly influence pain outcomes. The inclusion of cognitive strategies in the experimental group likely addressed these factors more effectively than conventional therapy alone. For example, cognitive interventions can reduce anxiety and depression, both of which are known to amplify pain perception through mechanisms such as increased muscle tension and heightened vigilance to pain. Additionally, improving patients' coping strategies through cognitive interventions can enhance their resilience to pain and reduce the likelihood of disability.¹⁶

Gate Control Theory and Cognitive Interventions

The gate control theory of pain, which is foundational to the neuromatrix theory, suggests that the perception of pain is modulated by a "gate" mechanism in the spinal cord that can be influenced by both physical and psychological factors. Cognitive interventions, such as those used in CPMx, can "close" the gate by reducing the emotional and cognitive amplification of pain signals. Techniques like relaxation, guided imagery, and cognitive restructuring are thought to decrease the transmission of pain signals through the spinal cord to the brain, thereby reducing the overall pain experience.¹⁷ This mechanistic understanding further supports the findings of this study, where the experimental group showed significant pain reduction.

Improving Physical Function and Quality of Life

The reduction in pain intensity achieved through cognitive interventions can have a cascading effect on physical function and overall quality of life. Pain often leads to fear-avoidance behaviors, where patients limit their physical activities due to the fear of exacerbating pain, which in turn can lead to deconditioning and further pain. By addressing the psychological aspects of pain through cognitive strategies, the experimental group may have experienced less fear and anxiety related to movement, leading to greater participation in physical therapy exercises, improved physical function, and better overall recovery.¹⁸

Implications for Clinical Practice

The findings of this study suggest that incorporating cognitive pain management strategies into standard physiotherapy practice could lead to better patient outcomes, particularly in preventing the progression of non-chronic sciatica to chronic sciatica. This has significant implications for clinical practice, especially in settings where chronic pain is prevalent and resources for multidisciplinary care are limited. Implementing cognitive interventions does not require significant additional resources but can lead to substantial improvements in patient outcomes, making it a cost-effective addition to conventional treatment protocols.¹⁹

In conclusion, the integration of CPMx strategies into conventional physical therapy offers a comprehensive approach to managing non-chronic sciatica, addressing both the physical and psychological dimensions of pain. This holistic approach not only reduces pain intensity but also prevents the chronicity of the condition, supporting the use of the BPS model in clinical settings.

Limitations

The study's small sample size of 30 participants limits generalizability, necessitating larger trials for more conclusive results. The short two-week intervention may not reflect long-term effects, underscoring the need for extended follow-ups. The lack of blinding could introduce bias, and the homogeneity of participants, restricted to English speakers with at least a graduate-level education, limits applicability to diverse populations. Additionally, the study did not deeply explore psychosocial factors, which could influence outcomes, suggesting a need for future research to consider these elements more thoroughly.

Future Scope

To enhance the study's robustness, future research should focus on conducting larger, multicenter trials and extending follow-up periods to assess the sustainability of treatment effects. Incorporating additional psychosocial interventions, such as stress management, and exploring personalized approaches tailored to individual profiles are crucial. Comparative studies with other conservative treatments and the use of neuroimaging techniques to understand the neural mechanisms of cognitive strategies are recommended. Finally, developing guidelines for the clinical integration of these strategies and evaluating their feasibility and cost-effectiveness is essential for advancing treatment options.

Conclusion

This study demonstrates that incorporating cognitive pain management strategies into conventional physical therapy significantly improves pain outcomes in non-chronic sciatica. The combined approach effectively reduces pain and may prevent the progression from acute to chronic pain. These findings support integrating cognitive strategies into standard physical therapy practices for enhanced patient outcomes.

Conflict of Interest

None