The effect of integrating pain neuroscience education with stabilization exercises using a flexi-bar on functional disability, pain, and geometry of abdominal and multifidus muscles in patients with chronic non-specific low back pain

OBJECTIVE: Chronic non-specific low back pain is a multifactorial condition encompassing both physical and psychosocial components, frequently characterized by maladaptive pain-related cognitions and fear-avoidance behaviours. Pain neuroscience education seeks to reconceptualize these cognitions and mitigate pain-related fear. This study evaluated the additional benefits of integrating pain neuroscience education with Flexi-Bar-based stabilization exercises on pain intensity, functional disability, and geometry of the abdominal and lumbar Multifidus muscles in individuals with chronic non-specific low back pain. METHODS: Forty-eight participants diagnosed with chronic non-specific low back pain were randomly allocated to one of two groups: (1) Pain neuroscience education followed by Flexi-Bar stabilization exercises or (2) Flexi-Bar stabilization exercises alone. Both groups underwent supervised Flexi-Bar stabilization training sessions three times a week for six weeks. The primary outcome was functional disability assessed by the Roland-Morris Questionnaire at baseline, immediately post-intervention, and at the 4-week follow-up. Secondary outcomes included pain intensity, kinesiophobia, pain catastrophizing, and fear-avoidance beliefs, all measured at the same three time points, as well as ultrasound-based geometry of abdominal and lumbar multifidus muscles, which was assessed at baseline and post-intervention in supine, seated, and standing positions. RESULT: Repeated-measures ANOVA revealed significant Time × Group interaction effects, main effects of time, and main effects of Group for both functional disability and pain intensity (p < 0.05). Ultrasound analysis demonstrated significant post-intervention increases in Transverse Abdominis and lumbar Multifidus muscle thickness across all tested positions (p < 0.05), with the pain neuroscience education plus exercise group exhibiting significantly greater increases compared to the exercise-only group. CONCLUSION: The combined PNE plus stabilization exercises yielded superior improvements in pain, disability, and muscle geometry compared with stabilization alone. However, the absence of a PNE-only group precludes isolating the educational component's unique contribution. Iranian Registry of Clinical Trials; prospectively registered (Trial number: IRCT20230505058095N1).