5 Ways to Improve Your Pain Neuroscience Education – A Student’s Perspective

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.


Key Points

  • 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.

5 responses to “5 Ways to Improve Your Pain Neuroscience Education – A Student’s Perspective

  1. Bryan says:

    The point about the patient hearing multiple explanations of their pain is an uphill battle with PNE. If PNE is going to become the better answer for those in pain we must work collaboratively with other medical providers. It’s no wonder people with fibromyalgia see a positive effect from psychological interventions as well as exercise.

    Moving forward I’m a firm believer that our relationships with physicians should continue to decrease and providers that help people with pain in the long term should be who we ally with. We need to work together and I don’t see physicians helping us in this pursuit in the near future.

  2. Cameron Yuen says:

    Bryan, I certainly agree that there needs to be consistency in the message and explanation given to these patients in pain. This became especially clear to me after listening to Peter O’Sullivan present over the last few weeks. I would say strengthening connections with physicians, though difficult, will need to improve as patients often hold onto those explanations given by physicians.

  3. GB says:

    I think you missed one:

    6) Avoid treatments which seem to contradict the message.

    Knowing that EIM has teamed up with Kinetacore, I would wonder how those who uphold science informed practice by leading treatment with therapeutic neuroscience education, then reconcile that through the eyes of a patient who just had their “trigger points” needled?

    How does that lend itself to self efficacy? (which is the ultimate end game of pain neuroscience education is it not? To empower patients to recognize that they are not fragile beings in need of “fixing” through external forces).

    By all means we can find better and more effective means to communicate pain neuroscience education however, if we persist with passive treatments which potentially unravel the message…what’s the point?

    If you glean the desired effect with dry needling (pain reduction) via (what appears to be) non specific means (placebo, DNIC or whatever)…and then expect to back track by suggesting that it was the nervous system that at full agency over the reduction….well….good luck with that.

    An already likely misinformed and probably stressed out and confused patient is only going to correlate the outcome with the needle…regardless of how the clinician tries to re-frame it.

    It’s all well and good to acknowledge the science but we have to stop trying to “square peg, round hole” this situation by somehow trying to fit our passive modalities AROUND the science.

    What we do before, during and after the TNE is probably the number 1 factor in “how to improve pain neuroscience education”

    Am I right?

    1. Ken Tanpinco says:

      I think that avoiding a passive treatment that has been successful in decreasing a patients pain (such as e-stim) completely is a great long term goal, but has to be done in a graded progression. We do preach avoiding boom-bust cycles when educating our patients to begin a new exercise program or pace themselves when they have a type A personality. Therefore, I think that it’s equally important to change some of their beliefs away from these passive modalities at a safe pace. Beliefs are part of what makes a person, and to take away those beliefs, no matter how anti-scientific they may be is taking away a part of who they are as a person. I recently had a patient who came to me 1 year after an e-stim implant for LBP. She has never turned it off since it was “installed,” nor stopped taking her pain medication. The implant became a part of her. I began sprinkling on TNE comments and telling her short 2-3 minute stories of how tissues and pain are 2 different issues. Eventually, she scheduled a time for me to give her a full 25 minute lecture at her request. I told her the plan was to see if we could begin turning down her implant 1x a day for 10 minutes to see what would happen. 6 weeks later, she had her e-stim turned off for 1 day a week, then 2, then 3 days. She then began reducing her pain medication by 25%, 50%, etc… until she was able to not feel any pain even with the machine off and without medication. Like I said, I think that we should eventually avoid using novel equipment, but it does have it’s place when used temporarily, and if used to allow appropriate coping responses of the nervous system. I tell my patients all the time that the best medical equipment (and clinician) is the one that makes itself obsolete the fastest. I still use hot packs in the clinic, but mention that they help provide Safety in my patients and that it will help them overcome and shrink Dangers in their life. “How will it do this?” they ask. That’s when I tell them about ion channels, the endocrine system, and educate them on how to calm their nervous system by pacing. So in the end, passive modalities are fine for me to use, as long as there is a scientifically sound explanation as to why I use them along with a firm understanding that it provides only temporary benefit and are inferior to exercise .

  4. GB says:

    While I agree in principle in exploiting passive treatments in an effort to gain patient confidence (that we can “within session” modify their symptoms), I maintain that it’s a slippery slope. I would also suggest that certain passive treatments (the more ritualistic and seemingly “skilled”) are harder to re-frame than others. Specifically dry needling and manipulation.

    The question here is…at what point to we transition from straight forward neuro-modulation…to overt deception? The topic of this thread is how best to communicate the science of pain to our patients. And I am going to suggest that the more ritualistic and invasive the procedure, the more challenging (probably impossible) it would be to perform the “bait and switch” art of re-framing the utilized modality in the context of pain neuroscience.

    I can certainly see using a hot pack to help calm things down (create a calming environment). I could even justify interferential current or some other minimally invasive tactic if I had to given that A) they are not invasive and B) there are minimal safety risks and C) the effects are more readily explained from a neurophysiological perspective.

    However when we start “upping the ante” by utilizing invasive procedures with known adverse effects, dubious scientific credibility and sparse (at best) evidence, I suspect we become part of the problem rather than part of the solution.

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