There has been a paradigm shift in the last few decades in our understanding of pain, and how to best treat it. Research is now exploring questions regarding the impact of beliefs and cognitions on pain, the interplay between the various biological systems on pain, and the role that physical therapists should take in the assessment and treatment of pain.
Findings from this research have been encouraging, and many valuable lessons can be found. For example, it is now firmly established that radiographic images and pain are not always associated, tissue damage and pain are not synonymous, and how educating patients about their pain can have profound positive effects.
The practical implementation of these findings into treatment has come to be known as Pain Neuroscience Education (PNE) and while relatively new, the ideas are steadily gaining traction. This is great news, and we should be optimistic about the impact we can have on our patients by empowering them with this knowledge.
But as with any new information, there is the danger that it can be applied incorrectly. David Butler has commented on this in the past after reading watered down versions of Explain Pain, and more recently described these approaches as “Explain Pain Lite.” He emphasizes that there are no shortcuts when it comes to changing these heavily entrenched beliefs, and advocates the use of a comprehensive curriculum when educating patients.
It can be difficult to determine how comprehensive this curriculum should be, and what should be included for each patient. In an excellent summary,Mira Meeus and Jo Nijs answer some of these questions as they review the literature, and provide several guidelines for improving the curriculum therapists deliver. The following suggestions are highlights from their review.
1. Direct Interaction with a Therapist
Though there is literature supporting the use of electronic and written education, direct individualized verbal interaction with a therapist has been found to be the superior delivery method. Delivered in this manner, exercise and movement interventions can be seamlessly integrated with the cognitive education, and patients are able to directly follow the therapist explanations with questions relating to their own experience of pain.
This direct question and answer interaction helps with what Adriaan Louw and others have described as deep learning. This process requires that the patient receives the information, internalizing the message, and applies it to their unique situation. Though some patients might not be ready for the message, and some may have difficulty applying it to their own situation, therapists are more likely to help with this process of deep learning through direct interaction.
2. Seek First to Understand, Then to be Understood
By the time a patient comes to see a therapist, it is possible that they have already been exposed to numerous explanations as to why they are in pain. Regardless of whether the explanations are accurate or helpful, it is likely that the patient has attached to the ones that make the most sense to them. Inquiring about these beliefs, and why the patient is attached to them, is a necessary first, especially if these beliefs run contrary to your planned curriculum.
>It is a mistake to think that every patient needs to fully reconceptualize their pain, and in some cases the education may be a very small piece of treatment. Communication and questionnaires will reveal who will benefit most from this education, but only once the patient begins doubting their own theories will they be open to discussion and new learning.
3. Individually Tailored Curriculum
There are many ways to educate patients, and while the information does need to be accurate, it also needs to make sense. This does not mean over simplified or watered down, but patients need to be able to understand the message for it to be of any help. This is where it is helpful to have many stories, metaphors, images, and examples to draw from that fit the patient’s unique circumstance. In some cases medical jargon can get in the way of deep learning, and in some cases it may be perfectly suitable. The content of PNE can be challenging, but a tailored approach for each patient should help with this process.
4. Believable and Beneficial Content
Similarly, the approach needs to be perceived as believable and beneficial. The patient is often looking for biological or structural reasons for their complaints, and the last thing they want to hear is a purely psychosomatic explanation. Delivered effectively, PNE can bridge this gap between structure and biology through a physiologic explanation that confirms that their pain is real, and that this pain has a biological explanation. This physiological confirmation that their pain is real, and the understanding that their biology can change, will help the patient see this new information as beneficial.
5. Reinforcement Through the Environment
The environment in this sense refers to relevant individuals in the patient’s life. This includes family, friends, and especially other healthcare professionals. If the messages explaining the patient’s pain remain conflicting or strictly biomedical in nature, it will be difficult for the patient to internalize the message and move forward with treatment.
Most importantly, these ideas should be reinforced in the environment of the therapy gym. If a new cognitive education is introduced, the movement education needs to be consistent with these messages. The language used in movement and exercise interventions can either confirm or refute the cognitive education, so therapists should aim for consistency and avoid reverting to older concepts.
- Growing evidence supports the ability of pain neuroscience education to positively impact patient outcomes.
- There is a danger that these new ideas can be applied incorrectly, but there are some guidelines that can help improve the delivery of the curriculum.
- Direct face to face interaction between therapist and patient allows for deep learning and improved comprehension.
- Seek first to understand what ideas and beliefs the patient has regarding their pain. New concepts cannot be introduced until current beliefs are addressed.
- The curriculum needs to be individually applied to the patient and their unique situation.
- The message must be interpreted as both believable and beneficial to the patient.
- The environment of the patient must support this new message. Most importantly, the messages must be consistent between healthcare professionals and in the language during movement education.