Physical therapists working with patients with chronic pain should consider use of Pain Neuroscience Education to help this population reach their goals.
Pain is a normal human experience, and without the ability to experience pain, people would not survive.1 Living in pain, however, is not normal.2 We often treat patients in physical therapy who have been struggling with pain for extended periods of time. Frequently it is difficult to overcome and seems to be impossible to resolve. One strategy to help people experience less pain and disability is to explain to people the biology and physiology of their pain experience.3 Much of our education as physical therapists guided us to educate patients on the anatomical and biomechanical aspects of pain. While this may be of great value for acute injuries or immediate postoperative periods, for chronic pain these traditional models may not only be limited in their efficacy but also induce fear.4 It has been proposed that this dichotomy of teaching people suffering from pain about anatomy, versus pain science, may be a reason why educational models often fail.5
Pain neuroscience education (PNE), also known as therapeutic neuroscience education (TNE), consists of educational sessions for patients describing in detail the neurobiology and neurophysiology of pain and pain processing by the nervous system.6 This educational approach has been used by physical therapist since 2002 in various countries and differs considerably from traditional education strategies such as back school and biomechanical models.7 This is due to how likelihood of pain chronicity may not likely be caused by unhealthy or dysfunctional tissues but brain plasticity leading to hyper-excitability of the central nervous system, known as central sensitization.8
The goal of this method is to change a patient’s perception of pain. Many patients believe that damaged tissues are the main cause for their pain. After a comprehensive evaluation to determine that damaged tissues are not the cause, education about pain neurophysiology helps the patient understand that pain may not correctly represent the health of the tissue but may be due to extra-sensitive nerves. As a result, patients have been found to have a reduction in fear avoidance behaviors and are more able and willing to move. PNE can be used with a combination of treatments, including exercise therapy that can be used to break down movement-related pain memories with graded exposure to exercise and decrease sensitivity of the nervous system.8
Here’s a brief example of therapeutic neuroscience education in practice taken from Louw et al., (2014). Suzy is experiencing pain and believes her pain is due to a bad disc. However, the pain has been there for 10 years. It is well established that discs reabsorb between 7-9 months and completely heal.9 So, why would it still hurt? She believes (as she has been told by clinicians) that her pain is caused by a bad disc. Now, we start explaining complex pain issues via a story/metaphor with the aim to change her beliefs, and then we set a treatment plan in place based on the new, more accurate neuroscience view of pain.
Therapist: “If you stepped on a rusted nail right now, would you want to know about it?”
Patient: “Of course.”
Therapist: “Why?”
Patient: “Well; to take the nail out of my foot and get a tetanus shot.”
Therapist: “Exactly. Now, how do you know there’s a nail in your foot? How does the nail get your attention?”
Therapist: “The human body contains over 400 nerves that, if strung together, would stretch 45 miles. All of these nerves have a little bit of electricity in them. This shows you’re alive. Does this make sense?”
Patient: “Yes.”
Therapist: “The nerves in your foot are always buzzing with a little bit of electricity in them. This is normal and shows….?”
Patient: “I’m alive.”
Therapist: “Yes. Now, once you step on the nail, the alarm system is activated. Once the alarm’s threshold is met, the alarm goes off, sending a danger message from your foot to your spinal cord and then on to the brain. Once the brain gets the danger message, the brain may produce pain. The pain stops you in your tracks, and you look at your foot to take care of the issue. Does this sound right?”
Patient: “Yes.”
Therapist: “Once we remove the nail, the alarm system should…?”
Patient: “Go down.”
Therapist: “Exactly. Over the next few days, the alarm system will calm down to its original level, so you will still feel your foot for a day or two. This is normal and expected.”
Therapist: “Here’s the important part. In one in four people, the alarm system will activate after an injury or stressful time, but never calm down to the original resting level. It remains extra sensitive. With the alarm system extra sensitive and close to the “firing level,” it does not take a lot of movement, stress or activity to activate the alarm system. When this happens, surely you think something MUST be wrong. Based on your examination today, I believe a large part of your pain is due to an extra-sensitive alarm system. So, instead of focusing of fixing tissues, we will work on a variety of strategies to help calm down your alarm system, which will steadily help you move more, experience less pain and return to previous function.”10
This example shows the shift in teaching about pain from a perspective that there is tissue damage to one that enables them to see pain from a sensitive nervous system perspective.
A full program of pain management should include this type of education with exercise and manual therapy. It has been shown that sessions that include education and exercise or manual therapy help remove doubt and develop a deep understanding of her pain experience.11 The patient should be encouraged to perform the key exercises to enhance movement as clinically reasoned through the evaluation and exercise portion of the encounter with focus on breathing and relaxation while doing them.12 Exercise should be monitored and guided using guidelines from Pain Neuroscience Education. The therapist should guide the patient to move their body or limb to the position at which they report a slight increase in pain intensity, just perceptibly above their baseline intensity. Once there, the patient is instructed to ask two questions: “Is this (movement or position) safe for my physical body?” and “Will I be okay later (if I move this much or stay in this position)?” With some practice and effort, the patient will find an amount of movement or postural change that feels safe, and that won’t likely flare the pain. At this point the patient is directed to divide their attention between their breath, body tension and the pain. Once aware of these, the patient should be instructed to do their best to keep their breath calm and their muscle tension low, while also attending to the pain, allowing self-monitoring that is unlikely to become hypervigilant or distracted.13
Various high quality randomized controlled trials and systematic reviews have shown increasing efficacy of PNE decreasing pain, disability, pain catastrophization, movement restrictions, and healthcare utilization.12 Physical therapist working with patients with chronic pain should consider use of Pain Neuroscience Education to help this population reach their goals.
References
- Moseley GL 2007a Reconceptualising pain according to modern pain sciences. Physical Therapy Reviews 12: 169–178
- Butler DS, Moseley LS 2003 Explain Pain. Adelaide, NOI Publications.
- Louw A, Butler DS 2011 Chronic pain. In: Brotzman SB, Manske RC (Eds), Clinical Orthopaedic Rehabilitation, 3rd edn. Philadelphia, PA, Elsevier.
- Greene DL, Appel AJ, Reinert SE, Palumbo M A 2005 Lumbar disc herniation: Evaluation of information on the internet. Spine 30: 826–829.
- Butler DS, Moseley LS 2003 Explain Pain. Adelaide, NOI Publications
- Louw, A., Diener, I., Butler, D.S. and Puentedura, E.J., (2011). The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of physical medicine and rehabilitation, 92(12), pp.2041-2056.
- Clarke, C.L., Ryan, C.G. and Martin, D.J., (2011). Pain neurophysiology education for the management of individuals with chronic low back pain: A systematic review and meta-analysis. Manual therapy, 16(6), pp.544-549.
- Nijs, J., Girbés, E.L., Lundberg, M., Malfliet, A. and Sterling, M. (2015). Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories. Manual therapy, 20 (1), pp. 216-220.
- Autio, R. A., Karppinen, J., Niinimaki, J., et al. (2006). Determinants of spontaneous resorption of intervertebral disc herniations. Spine, 31(11), 1247-1252.
- Louw A. (2014). Therapeutic Neuroscience Education: Teaching People About Pain
- Zimney K, Louw A, Puentedura E J 2014 Use of Therapeutic Neuroscience Education to address psychosocial factors associated with acute low back pain: A case report. Physiotherapy Theory and Practice 30: 202–209.
- Louw A, Zimney K, O’Hotto C, Hilton S. The clinical application of teaching people about pain. Physiother Theory Pract. 2016 Jul;32(5):385-95. doi: 10.1080/09593985.2016.1194652. Epub 2016 Jun 28. Review. PubMed PMID: 27351903.
- Blickenstaff, Cory & Pearson, PT, MSc (RHBS), BA-BPHE, Neil. (2016). Reconciling movement and exercise with pain neuroscience education: A case for consistent education. Physiotherapy Theory and Practice. 32. 1-12. 10.1080/09593985.2016.1194653.
