Implementing pain neuroscience education (PNE) into practice has revolutionized my career. The ability to re-frame a patient’s pain experience with modern explanations of pain, built on a biopsychosocial foundation, has been a professional game changer. Though this shift has not occurred without bumps and bruises along the way. While I have used PNE to help countless people shift threat, move through pain, and ultimately restore function, sometimes PNE goes wrong. Learning from these stray interactions by asking myself why, taking time to reflect, adjusting style, and persisting have been essential for success. This blog will consider four ways for patients to hear the key messages of the PNE, without entering the wrong door.
When PNE goes wrong, or not as expected, it is like entering the wrong door. Choosing a wrong door often has consequences. The game show contestant chooses door one and gets a nice set of dishes instead of a new car. Accidentally walking into the wrong bathroom door never goes well. Of course there is the wrong door on the Seinfeld “shrinkage” episode. Then you have the cliché movie scene when a guy walks through the door of a bar in place he should not be. The record screeches, all goes quiet, and everyone stares. Nothing but crickets………
Imagine a chronic pain patient as a house containing many doors. The doors are barriers that can be open or shut. These doors lead to various parts of a patient’s life, body systems, beliefs, and experiences. In this house of many doors there is at least one door, which if opened, will lead to a successful outcome. Though entering the wrong door creates an immediate closing and an inability to apply effective treatment. The skill of implementing PNE well is deciding which doors to enter, which ones to keep closed, and how quickly or slowly to open the doors.
Below are four doors to consider using caution when first implementing PNE.
Door 1: Patient Beliefs
Shifting patient beliefs is a cornerstone of PNE and is essential to do. But, trying to change beliefs too forcefully is an error. No one appreciates being force fed a new belief. Current beliefs exist for a reason and have likely been there for some time. PNE provides an opportunity to shine light on how pain works while altering threat, and thus provides the patient an ability to hopefully form a new belief by himself. Changing beliefs changes behavior, but go at a pace that feels natural and not forced.
Door 2: Lack of Insight Into Past Experiences
Thorough examinations are always required here. Listening to hear the whole story is vital to understand. Missing key nociceptive or neurogenic drivers of pain during a physical exam often leads to the wrong door. It is enticing to jump into treating pain quickly because of the personal confidence PNE knowledge creates. I have entered this door too many times, too quickly without a complete exam. Entering too soon creates missed opportunities for finding superior starting points for treatment. Once entered, it is hard to go back.
Door 3: Using Too Much Detail About a Particular Body System
Talking about pain being in the “brain” too much, too soon, no doubt increases the chance of a patient saying “oh, you think this pain is in my head.” This statement is often followed by a dirty look or a four letter word. Discussing the brain as part of the overall nervous system and being part of how pain is processed helps guard against too much “brain” talk. The secret is teaching that pain is of the brain, without saying “pain is of the brain”.
Door 4: A patient’s busy life
Living with persistent pain is hard. Common sense suggests the busier a human is, the less time there is for self-reflection, change, and growth. All qualities required to treat pain well. Considering the big picture of a patient’s life is vital. Assuming a patient is ready to change just because of a decision to attend PT is not always correct. At times, a patient is in PT out of insistence from a doctor, and may have little personal drive or time to improve. Not because of a lack of desire to have less pain, but life is just too busy. Figuring this out is important. If you perceive someone is not ready to take on the bigger picture of persistent pain, it is ok to be up font about the commitment needed for success, in a caring way. Sometimes it is better to help with only the current pain and functional problems vs. taking on the bigger picture of the ongoing pain. Giving options and allowing a patient to assist in treatment decisions can save frustration for the patient and therapist. But in these cases, there is always the planting of PNE seeds during treatment. Doing so with compassion may create a connection that will allow for future successful treatments.
Aspects of PNE are almost always the right message, but finding the best door to enter treatment can be challenging. This was especially true for me early on as I learned PNE. Clinicians bound by time and work demands often open doors too soon or rush through doors that are not ready to be opened. Trust me, I have rushed through many doors and opened some that I should have kept shut. Even with the best intentions, it still happens. Through taking time to listen, completing outcome tools, performing physical assessments, and using clinical reasoning will point to the best doors more often.
What do you think?