Is Pain Neuroscience Education the Same as Cognitive Behavioral Therapy?

We often get the question: is pain neuroscience education the same as cognitive behavioral therapy? The literal answer is no. Cognitive behavioral therapy (CBT) is a psychosocial intervention that is based on a combination of basic principles from behavioral and cognitive psychology. It was originally designed to treat depression, but is now used for various mental disorders. To deliver CBT, one should receive specific training in the technique. With that in mind, does pain neuroscience education (PNE) contain components that are based on CBT principles? Our consensus is, yes.

In discussion with Jo Nijs, he agreed that PNE is probably mostly about the “C” of CBT. PNE is trying to change an individual’s perceptions about their injury/illness and beliefs about pain, aka the cognitive component. This is where understanding the neurophysiology of pain along with having the ability to change perceptions about various tissue variances that an individual in pain has is important. How one goes about this is through the various metaphors and stories to assist with the patient’s understanding. I like to make a point that knowing about pain science is not the same as treating a patient utilizing pain science. For me it is no different from knowing anatomy and biomechanics is not the same thing as treating a patient utilizing these principles. Sure, you need to have a sound knowledge of anatomy and biomechanics, but you need a lot more to be able to effectively treat a patient. I get concerned some clinicians may be content with knowing pain science, yet they have not been able to effectively use it within the treatment of individuals with pain. We recently finished an fMRI study that showed when we use PNE; we affect specific areas of the brain associated with the pain neuromatrix. These changes are different from when we used a control (non-PNE) educational process. The patient cognitively starts to think differently after they receive PNE.

Even if one is effective in delivering PNE, the “C” portion of CBT, it is limited in its effectiveness. Our past research has shown that unless the PNE is followed up with the active behavior change, the “B” of CBT, it has limited effectiveness.

Put more simply: you cannot explain someone’s pain away. For us in therapy we have been in the behavior change business since the start of our profession.

The primary behaviors we work on are exercise, movement, relaxation, motor control, goal setting, graded exposure, etc. We can also do some behavior therapy in the areas of sleep hygiene, diet, meditation, etc. This should be in every good clinician’s wheelhouse to change behavior in our patients. While behavior change is hard, this is what we are trained to help with.

So why do you need to deliver PNE first then work on the behavior change? We know from our and other fMRI studies that PNE changes the “filter”, how the brain “scrutinizes” as Louis Gifford mentioned in his Mature Organism Model. A patient then needs to run the behavior through the new “filter”/cognitions in order to generate the output that becomes new inputs. It is the running of the behavior through the new filter repetitively over time that allows for changes eventually in pain and function. A new filter is worthless unless you run things through it to filter. Thus, PNE without the active behavior change activities is not very effective. The neat part about the filter of the brain is that exercise actually makes the filter get better over time as it releases BDNF, serotonin and other good chemicals to allow the filter to function better. Moreover, as we move the filter learns about the body better (sharpens the homunculus) with increased body awareness and thus learns through expectancy violation, that it can function without the production of pain in all situations.

Therefore, while PNE is not CBT, it does use evidence-based principles of CBT by changing a person’s cognitions and then eventually using behavior change principles to make long-term changes to help an individual return to a level that they can function better again. What say you?

9 responses to “Is Pain Neuroscience Education the Same as Cognitive Behavioral Therapy?

  1. Dan Kangaroo says:

    This is an excellent post on clarifying between PNE and CBT. What do you think about CFT and some of Dankerts, O’Sullivan Peter and Kieran (Pain-Ed group)? Thanks again

  2. Kory Zimney says:

    I haven’t specifically taken any CFT training by the Pain-Ed group, so I can only answer from my interpretation from reading their methods section from their published work. It would appear that they are providing PNE and then putting that in a framework for their targeted exercise program. So this would be in-line with providing the “C” portion with the PNE and then helping the patient with the active component of treatment, the “B”, by providing exercises and movement options. Everything I have read of their work fits in line with my current thinking of how we can best treat individuals suffering from painful conditions.

    1. Mark Kargela says:

      I asked Peter O’Sullivan about PNE and he indicated it wasn’t a big part of his CFT practice. It seemed to be more exposure based treatments and behavioral experiments. They definitely confronted maladaptive beliefs about fragile/damaged structure but it didn’t get deep into PNE from what I saw

      Great post Kory!

  3. Larry says:

    Very good summary. Yes, some overlap but CBT is not meant for PT’s any more than manual therapy is meant for psychologists with CBT certification. What we are starting to see thankfully is the integration of transportable positive pychology inteventions and concepts as well many gleaned from social neuroscience. The distinction is important. Use of various concepts found outside of the PT literature should not be limited to chronic pain but should be integrated across all patients and all settings. We are beginning to see many ways that these concepts are also used preventatively and definitely in work comp cases

    1. Kory Zimney says:

      Larry, it is very good to see this gradual transition of understanding the importance of psychosocial factors (just wish it was happening a bit faster).

  4. John Ware, PT says:

    I like your analogy of PNE changing the “filter” so that we can re-conceptualize what it means when our body processes inputs that have been perceived as threatening in the past. I also use Moseley’s analogy of “preparing the soil” so that movement takes place in a new, rich and fertile environment where new behaviors can be allowed to grow and flourish. But you still have to tend to the garden, and you’ll have to pull some weeds from time to time. You also may have periods of drought or storms that require you to replant. But, at least you have the soil there for behaviors to grow again. At the very least, you have the knowledge of how to rejuvenate the soil to make it rich and fertile again.

    1. Kory Zimney says:

      John, thanks for sharing another useful metaphor that we can use with our patients. Education is never enough, you need to have the behavior change with movement come along side the knowledge.

  5. Rodrigo says:

    The article gave a basic explanation about CFT cognitive functional therapy. The Peter O sullivan system which is growing fast as a first option to treat patients with chronic non specific low back pain

  6. Cesar B Waisberg says:

    It’s a very good combination. As much as PTs normally do not have expertise in psychological therapies, it’s important to highlight that very few of us have a chance to work in a multidisciplinary setting. That compells us to go a little deeper in behavior therapies as well. Also important to mention how essential it is change in behavior when it comes to chronic pain patients. Thumbs up for those who already are able to apply PNE and CBT as part of the approach!!!

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