Palmitoylethanolamide Modulates Central Sensitisation and Neuroinflammation in Chronic Low Back Pain

August 17, 2026 updated by: Hager Essam Nasrallah, Beni-Suef University

Palmitoylethanolamide Modulates Central Sensitisation and Neuroinflammation in Chronic Low Back Pain: A Randomized Controlled Trial With Neurophysiological and Biomarker Correlates

Low back pain (LBP) is a public and occupational health problem that is a major professional, economic and social burden. Up to 84% of the general population will experience an episode of LBP during its life time, and recurrence rates are high. Acute LBP is the second reason for consultations in general medicine, and chronic LBP is the eighth. One in five LBP episodes result in sick leave. LBP represents 30% of sick leaves that are longer than 6 months, and 20% of work accidents. LBP has become the leading cause of exclusion from work before the age of 45, and the third cause of work disabilities in France.

In 2020 globally, LBP affected approximately 619 million people, making it the leading cause of disability worldwide. This number is projected to rise to 843 million by 2050, driven by population growth and aging.

Study Overview

Status

Recruiting

Conditions

Intervention / Treatment

Detailed Description

Chronic LBP is a heterogenous condition with mixed nociceptive and neuropathic components in many patients. Mechanisms that sustain chronicity include ongoing peripheral nociceptor sensitization, neuroimmune activation (mast cells, microglia), and maladaptive central nervous system plasticity (altered cortical excitability, changes in descending modulatory systems).

Pro-inflammatory cytokines such as TNF-α and IL-1β have been implicated in maintenance of peripheral and central sensitization and the transition from acute to chronic pain. Measuring an inflammatory biomarker (e.g., serum TNF-α) alongside clinical pain and neurophysiological markers can therefore help test an anti-neuroinflammatory treatment hypothesis.

Today's management of chronic LBP includes analgesics (paracetamol), non-steroidal anti-inflammatory drugs, antidepressants, anticonvulsants, opioids, and topical treatments , with oral agents recommended as first-line therapy. Analgesics and non-steroidal anti-inflammatory drugs target the nociceptive component of LBP without affecting neuropathic pain components, while opioids target both nociceptive and (to a lesser degree) neuropathic pain, and antidepressants target only the neuropathic component, although data concerning their efficacy is conflicting.

Analgesics and non-steroidal anti-inflammatory drugs target the nociceptive component of LBP without affecting neuropathic pain components, while opioids target both nociceptive and (to a lesser degree) neuropathic pain, and antidepressants target only the neuropathic component, although data concerning their efficacy is conflicting.

Although relieving neuropathic pain to some extent, classical opioid analgesics suffer from frequent side effects, particularly at the gastrointestinal level that limit their long-term use. An innovative approach in the management of chronic pain diseases is represented by palmitoylethanolamide (PEA), a member of the N-acylethanolamine family, produced by most mammalian cells and which is particularly abundant in brain tissues.

PEA is involved in endogenous protective mechanisms activated by stimulation of inflammatory responses. PEA exerts its effects on cellular targets involved in the generation and maintenance of pain by down-modulating mast cell activation and controlling microglial cell behaviors.

PEA acts through several complementary mechanisms that are relevant to chronic pain: PEA is a ligand of peroxisome proliferator-activated receptor alpha (PPAR-α); activation has anti-inflammatory and analgesic consequences., Mast cell stabilization / Autacoid Local Inflammation Antagonism (ALIA) mechanism: PEA reduces mast cell degranulation and local release of pro-nociceptive mediators, historically described as ALIA. Indirect endocannabinoid-modulating effects: PEA can indirectly modulate the endocannabinoid system, contributing to analgesia without psychotropic effects. Biomarkers can be used to aid diagnosis, clarify disease pathophysiology, classify the extent of a disease, indicate disease prognosis, and predict or monitor the disease over time and in response to interventions.

Central sensitization is defined by the International Association for the Study of Pain (IASP) as an increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input . Historically, the discovery that injury at peripheral tissues induces hyperexcitability of spinal cord nociceptive neurons has prompted a massive research effort that has consistently confirmed enhanced responsiveness of central nociceptive pathways with different animal models.

One proposed biomarker for assessing CNS pathophysiology in chronic pain is transcranial magnetic stimulation (TMS). TMS uses electromagnetic induction to noninvasively generate an electrical current in the brain.TMS involves a high-current pulse generator that discharges an electrical current of several thousand amperes through an insulated metal stimulating coil for a period of < 1ms, generating a brief and focal magnetic field of approximately 1 to 2 Tesla-].

When the coil is placed on an individual's scalp overlying the primary motor cortex (M1), the magnetic field can induce an intracortical electric current sufficient to depolarize superficial corticospinal neurons and activate a target muscle leading to a measurable electromyographic responseThe neurotransmitters involved in various TMS-evoked measurements have been well characterized thus making TMS a putative biomarker for the study of chronic pain.

Mechanistic link between TNF-α and TMS measures:Neuroinflammation, characterized by elevated levels of proinflammatory cytokines such as tumor necrosis factor-alpha (TNF-α), can profoundly influence cortical excitability. TNF-α modulates synaptic transmission by enhancing AMPA receptor trafficking to the postsynaptic membrane and reducing GABA_A receptor surface expression, leading to an imbalance between excitatory and inhibitory neurotransmission.

This cytokine-driven shift toward hyperexcitability alters the functional state of intracortical circuits. Transcranial magnetic stimulation (TMS) provides a noninvasive means to quantify these changes: short-interval intracortical inhibition (SICI) reflects GABA_A-mediated inhibitory tone, while intracortical facilitation (ICF) reflects glutamatergic excitatory activity.

Study Type

Interventional

Enrollment (Estimated)

106

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Contact Backup

  • Name: Wael Fathy Hassan, M.D

Study Locations

  • Egypt
      • Banī Suwayf, Egypt
        • Recruiting
        • Beni Suef University Hospital
        • Contact:
          • Mohamed Abdelbadie Ali, Lecturer
        • Contact:
          • Marwa Abd elsalam khames Elgaly, Lecturer

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Adult
  • Older Adult

Accepts Healthy Volunteers

No

Description

Inclusion Criteria:

  • With chronic pain (more than 3 months)
  • Patients with NRS (4 -7)
  • MRI evidence of disc protrusion or prolapse limited to one or two lumbar discs, without extensive multi-level pathology
  • Diagnosed clinically with low back pain due to disc disease.
  • ASA I and ASA II

Exclusion Criteria:

  • Neurological disorders
  • psychiatric illness
  • pregnancy
  • prior spinal surgery
  • concurrent use of immunomodulatory drugs
  • contraindications to TMS.
  • Allergy to the drug

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Active Comparator: Micronized Palmitoylethanolamide Group
About 53 patients suffering from low back pain will receive Micronized Palmitoylethanolamide 600 mg tablets orally twice daily with the traditional treatment (NSAIDs, muscle relaxant and gabapentin): and physiotherapy for 6 months.
Drug: Palmitoylethanolamide
to evaluate the effect of PEA and traditional treatment versus traditional treatment alone for the patiens with chronic low back pain on pain intensity, disability and patient satisfaction at baseline, 3 months, and 6 months.
Other Names:
  • traditional treatment
Active Comparator: Control group
About 53 patients suffering from low back pain will receive Traditional treatment (NSAIDs, Muscle relaxant, gabapentin) and physiotherapy.
Drug: Palmitoylethanolamide
to evaluate the effect of PEA and traditional treatment versus traditional treatment alone for the patiens with chronic low back pain on pain intensity, disability and patient satisfaction at baseline, 3 months, and 6 months.
Other Names:
  • traditional treatment

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Treatment of Chronic Low Back Pain
Time Frame: 6 Months
Number of Participants With Treatment by adjunctive Palmitoylethanolamide Assessed by reducing pain intensity from baseline to 3 months and 6 months following treatment initiation, as measured by the Numeric Rating Scale (NRS). NRS ranges from 0 = no pain to 10 = worst imaginable pain.
6 Months

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Beni-Suef University

Investigators

  • Study Chair: Hatem Elmoutaz Mahmoud, M.D, Professor of Anaesthesiology,Surgical intensive care and pain management,Faculty of medicine

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

January 1, 2026

Primary Completion (Estimated)

June 1, 2027

Study Completion (Estimated)

June 10, 2027

Study Registration Dates

First Submitted

August 12, 2026

First Submitted That Met QC Criteria

August 17, 2026

First Posted (Actual)

August 19, 2026

Study Record Updates

Last Update Posted (Actual)

August 19, 2026

Last Update Submitted That Met QC Criteria

August 17, 2026

Last Verified

January 1, 2026

More Information

Terms related to this study

Additional Relevant MeSH Terms

Other Study ID Numbers

  • Chronic Low Back Pain

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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