Skip to main content

De-educate to re-educate: aging and low back pain



Patients’ beliefs about their condition have been shown to play a significant role in their pain experience and response to treatment, especially when a patient sees their tissue health as vulnerable or aged. Educational can alter these beliefs. Prior to new information, patients often have to be de-educated regarding common misbeliefs to undergo re-education.


To determine if a brief de-education session regarding aging and low back pain (LBP) can shift pain ratings, fear-avoidance beliefs, beliefs regarding aging and LBP, and limited active trunk flexion.


Fifty adults ranging from 50 to 93 years of age (SD = 10.73) with a 15.1 years of LBP were education on the poor correlation between aging and LBP. Prior to and immediately after the education pain ratings for LBP and leg pain (numeric pain rating scale—NPRS), fear-avoidance (fear avoidance beliefs questionnaire—FABQ), beliefs regarding aging and LBP (Likert scale) and active trunk flexion were measured.


Significant changes were found in positive shifts with LBP (p = 0.002), leg pain (p = 0.042), FABQ-physical activity subscale (p = 0.004) and active trunk forward flexion (p < 0.001).


The results show that education aimed at altering beliefs regarding LBP and aging result in a positive shift in pain, fear avoidance related to physical activity and active trunk flexion.


Prior to providing patients with new healthcare information, de-educating them regarding poor beliefs may be helpful in shifting them towards new, healthier paradigms associated with their condition.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4


  1. 1.

    Gehrt TB et al (2015) The role of illness perceptions in predicting outcome after acute whiplash trauma: a multicenter 12-month follow-up study. Clin J Pain 31:14–20

    Article  PubMed  Google Scholar 

  2. 2.

    Vlaeyen JW, Crombez G, Linton SJ (2009) The fear-avoidance model of pain: we are not there yet. Comment on Wideman et al. “A prospective sequential analysis of the fear-avoidance model of pain” [Pain, 2009] and Nicholas “First things first: reduction in catastrophizing before fear of movement” [Pain, 2009]. Pain 146:222. (author reply 222-3)

    Article  PubMed  Google Scholar 

  3. 3.

    Vlaeyen JW, Linton SJ (2000) Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 85:317–332

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Linton SJ (2000) A review of psychological risk factors in back and neck pain. Spine 25:1148–1156

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Nijs J et al (2013) Thinking beyond muscles and joints: therapists’ and patients’ attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Man Ther 18:96–102

    Article  PubMed  Google Scholar 

  6. 6.

    Moseley GL (2007) Reconceptualising pain acording to modern pain sciences. Phys Ther Rev 12:169–178

    Article  Google Scholar 

  7. 7.

    Louw A, Diener I, Puentedura E (2014) Comparison of terminology in patient education booklets for lumbar surgery. Int J Health Sci 2:47–56

    Google Scholar 

  8. 8.

    Louw A et al (2016) The clinical application of teaching people about pain. Physiother Theory Pract 32:385–395

    Article  PubMed  Google Scholar 

  9. 9.

    Moseley GL, Hodges PW, Nicholas MK (2004) A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain 20:324–330

    Article  PubMed  Google Scholar 

  10. 10.

    Moseley L (2002) Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother 48:297–302

    Article  PubMed  Google Scholar 

  11. 11.

    Meeus M et al (2010) Pain physiology education improves pain beliefs in patients with chronic fatigue syndrome compared with pacing and self-management education: a double-blind randomized controlled trial. Arch Phys Med Rehabil 91:1153–1159

    Article  PubMed  Google Scholar 

  12. 12.

    Louw A et al (2011) The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil 92:2041–2056

    Article  PubMed  Google Scholar 

  13. 13.

    Louw A et al (2016) The efficacy of pain neuroscience education on musculoskeletal pain: a systematic review of the literature. Physiother Theory Pract 32:332–355

    Article  PubMed  Google Scholar 

  14. 14.

    Moseley GL (2003) Joining forces—combining cognition-targeted motor control training with group or individual pain physiology education: a successful treatment for chronic low back pain. J Manual Manip Ther 11:88–94

    Article  Google Scholar 

  15. 15.

    Moseley G (2002) Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physio 48:297–302

    Article  Google Scholar 

  16. 16.

    Puentedura EJ et al (2010) Rehabilitation following lumbosacral percutaneous nucleoplasty: a case report. J Orthop Sports Phys Ther 40:214–224

    Article  PubMed  Google Scholar 

  17. 17.

    Louw A et al (2013) Development of a preoperative neuroscience educational program for patients with lumbar radiculopathy. Am J Phys Med Rehabil 92:446–452

    Article  PubMed  Google Scholar 

  18. 18.

    Lluch Girbes E et al (2015) Balancing “hands-on” with “hands-off” physical therapy interventions for the treatment of central sensitization pain in osteoarthritis. Man Ther 20:349–352

    CAS  Article  PubMed  Google Scholar 

  19. 19.

    Louw A et al (2016) Know pain, know gain? A perspective on pain neuroscience education in physical therapy. J Orthop Sports Phys Ther 46:131–134

    Article  PubMed  Google Scholar 

  20. 20.

    Diener I, Kargela M, Louw A (2016) Listening is therapy: patient interviewing from a pain science perspective. Physiother Theory Pract 32:356–367

    Article  PubMed  Google Scholar 

  21. 21.

    Wijma AJ et al (2016) Clinical biopsychosocial physiotherapy assessment of patients with chronic pain: the first step in pain neuroscience education. Physiother Theory Pract 32:368–384

    Article  PubMed  Google Scholar 

  22. 22.

    Louw A, Puentedura EL, Mintken P (2012) Use of an abbreviated neuroscience education approach in the treatment of chronic low back pain: a case report. Physiother Theory Pract 28:50–62

    Article  PubMed  Google Scholar 

  23. 23.

    Louw A (2014) Therapeutic neuroscience education via e-mail: a case report. Physiotherapy theory and practice

  24. 24.

    Zimney K, Louw A, Puentedura EJ (2014) Use of therapeutic neuroscience education to address psychosocial factors associated with acute low back pain: a case report. Physiother Theory Pract 30:202–209

    Article  PubMed  Google Scholar 

  25. 25.

    Moseley GL (2005) Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI evaluation of a single patient with chronic low back pain. Aust J Physiother 51:49–52

    Article  PubMed  Google Scholar 

  26. 26.

    Cleland JA, Childs JD, Whitman JM (2008) Psychometric properties of the neck disability index and numeric pain rating scale in patients with mechanical neck pain. Arch Phys Med Rehabil 89:69–74

    Article  PubMed  Google Scholar 

  27. 27.

    Salaffi F et al (2004) Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. Eur J Pain 8:283–291

    Article  PubMed  Google Scholar 

  28. 28.

    Cleland JA, Fritz JM, Childs JD (2008) Psychometric properties of the fear-avoidance beliefs Questionnaire and tampa scale of kinesiophobia in patients with neck pain. Am J Phys Med Rehabil 87:109–117

    Article  PubMed  Google Scholar 

  29. 29.

    Grotle M, Vollestad NK, Brox JI (2006) Clinical course and impact of fear-avoidance beliefs in low back pain: prospective cohort study of acute and chronic low back pain: II. Spine 31:1038–1046

    Article  PubMed  Google Scholar 

  30. 30.

    Poiraudeau S et al (2006) Fear-avoidance beliefs about back pain in patients with subacute low back pain. Pain 124:305–311

    CAS  Article  PubMed  Google Scholar 

  31. 31.

    Fritz JM, George SZ (2002) Identifying psychosocial variables in patients with acute work-related low back pain: the importance of fear-avoidance beliefs. Phys Ther 82:973–983

    PubMed  Google Scholar 

  32. 32.

    Burton AK et al (1999) Information and advice to patients with back pain can have a positive effect. A randomized controlled trial of a novel educational booklet in primary care. Spine 24:2484–2491

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    George SZ, Fritz JM, McNeil DW (2006) Fear-avoidance beliefs as measured by the fear-avoidance beliefs questionnaire: change in fear-avoidance beliefs questionnaire is predictive of change in self-report of disability and pain intensity for patients with acute low back pain. Clin J Pain 22:197–203

    Article  PubMed  Google Scholar 

  34. 34.

    Sloan TJ, Walsh DA (2010) Explanatory and diagnostic labels and perceived prognosis in chronic low back pain. Spine (Phila Pa 1976) 35:E1120–5

    Article  Google Scholar 

  35. 35.

    Moseley GL (2004) Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. Eur J Pain 8:39–45

    Article  PubMed  Google Scholar 

  36. 36.

    Ekedahl H, Jonsson B, Frobell RB (2012) Fingertip-to-floor test and straight leg raising test: validity, responsiveness, and predictive value in patients with acute/subacute low back pain. Arch Phys Med Rehabil 93:2210–2215

    Article  PubMed  Google Scholar 

  37. 37.

    Louw A, Flynn TW, Puentedura E (2015) Everyone has back pain. OPTP, Minneapolis

    Google Scholar 

  38. 38.

    Twomey LT, Taylor JR (1987) Age changes in lumbar vertebrae and intervertebral discs. Clin Orthop Relat Res 224:97–104

    Google Scholar 

  39. 39.

    Taylor JR, Twomey LT (1986) Age changes in lumbar zygapophyseal joints. Observations on structure and function. Spine (Phila Pa 1976) 11:739–745

    CAS  Article  Google Scholar 

  40. 40.

    Kjaer P et al (2005) Magnetic resonance imaging and low back pain in adults: a diagnostic imaging study of 40-year-old men and women. Spine 30:1173–1180

    Article  PubMed  Google Scholar 

  41. 41.

    Videman T et al (2003) Associations between back pain history and lumbar MRI findings. Spine 28:582–588

    PubMed  Google Scholar 

  42. 42.

    Deyo RA, Mirza SK, Martin BI (2006) Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine 31:2724–2727

    Article  PubMed  Google Scholar 

  43. 43.

    Gignac MA et al (2006) “What do you expect? You’re just getting older”: a comparison of perceived osteoarthritis-related and aging-related health experiences in middle- and older-age adults. Arthritis Rheum 55:905–912

    Article  PubMed  Google Scholar 

  44. 44.

    Thielke S, Sale J, Reid MC (2012) Aging: are these 4 pain myths complicating care? J Fam Pract 61:666–670

    PubMed  PubMed Central  Google Scholar 

  45. 45.

    Moseley GL et al (2008) Thinking about movement hurts: the effect of motor imagery on pain and swelling in people with chronic arm pain. Arthritis Rheum 59:623–631

    Article  PubMed  Google Scholar 

  46. 46.

    Louw A, Diener I, Puentedura EJ (2015) The short term effects of preoperative neuroscience education for lumbar radiculopathy: a case series. Int J Spine Surg 9:11

    Article  PubMed  PubMed Central  Google Scholar 

  47. 47.

    Jull G, Sterling M (2009) Bring back the biopsychosocial model for neck pain disorders. Man Ther 14:117–118

    Article  PubMed  Google Scholar 

  48. 48.

    Moseley GL, Butler DS (2015) Fifteen years of explaining pain: the past, present, and future. J Pain Off J Am Pain Soc

  49. 49.

    Verbeek J et al (2004) Patient expectations of treatment for back pain: a systematic review of qualitative and quantitative studies. Spine 29:2309–2318

    Article  PubMed  Google Scholar 

  50. 50.

    Hopayian K, Notley C (2014) A systematic review of low back pain and sciatica patients’ expectations and experiences of health care. Spine J 14:1769–1780

    Article  PubMed  Google Scholar 

  51. 51.

    Gross A et al. (2012) Patient education for neck pain. Cochrane Database Syst Rev 3:CD005106

    Google Scholar 

  52. 52.

    McDonald S, Hetrick S, Green S (2004) Pre-operative education for hip or knee replacement. Cochrane Database Syst Rev:CD003526

    Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Adriaan Louw.

Ethics declarations

Conflict of interest

No conflicts to be reported by any authors pertaining to this paper.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Louw, A., Zimney, K., Johnson, E.A. et al. De-educate to re-educate: aging and low back pain. Aging Clin Exp Res 29, 1261–1269 (2017).

Download citation


  • Pain Experience
  • Minimal Clinical Important Difference
  • Positive Shift
  • Tissue Health
  • Pain Catastrophization