When Pain Education Isn’t Enough

Although I truly appreciate all the work that has been done in the pain sciences world, it still isn’t enough to help guide our clinical decision making process.

I have unanswered questions: which patients are the best candidates for pain education? How soon should a change occur? How much of a change is enough to warrant a positive response to pain education?

Earlier this year I had a younger lady who finished her military career enter my doors. She had been serving in the Air Force. She had been in Iraq and Afghanistan. She did field work in Delaware. She returned to Michigan because this is where her life began. Her parents were gone. Apparently her Dad was a mean drunk. Her Mom was psychotic. This patient basically raised her siblings from the age of 11 – figuring out what to eat/cook… making sure they all went to school… protecting them as much as possible from their Dad. Her Mom committed suicide a few years ago. This lady experienced a divorce a couple of years ago. She sought out services because she had ongoing back pain for about a year. She had been seeing a chiropractor for 9 months (with no results). She did field work in Michigan testing lake, pond and river waters. The job was quite strenuous and required hauling buckets and gear 2-5 miles: at times without a 4-wheeler… many times without a dolly. She had been missing work due to her back pain. She was also feeling more and more fatigued which she related to being sick and tired of hurting.

My initial critical thinking was focused on a few things. It seems she had persistent back pain that had not responded to conservative care. As I thought about pain science and pain education, she had months and months of being told the anatomical reason for her back pain. Her psychosocial history indicated yellow flags.

Probably not surprising to most of you, the examination process was boring. I found no objective findings. I didn’t see any red flags. I took a mental deep breath and spent some time educating her about pain. She was a really good thinker and asked great questions. Because of her psychosocial history, she had an active professional helping her with her past. We came up with a game plan.

On her third visit, as I was working with her, she experienced some unexpected knee pain. She also reported that she was beginning to have ankle and shoulder pain during the day. I didn’t really comment or address this.

On her fourth visit, my alarm bells were clanging in my head. I was not finding anything objectively and she was reporting increased back pain, multiple joint pain and increasing fatigue. Nothing was making sense. I felt like kicking myself for initially connecting dots and making the assumption that she had persistent pain which hadn’t been addressed with pain education. On this visit, I spent time regrouping: what had I missed… what didn’t I ask? One piece I missed: in Delaware while doing her field work, it was very common for her to come home with multiple ticks on her body. About 2 years ago, she had a bite get infected. She received treatment. She never had any bloodwork done. Lyme disease needed to be ruled out. I contacted her primary care physician with recommendations to rule out Lyme disease.

She tested negative. Her primary care physician saw something in her lab work. She was referred to a rheumatologist. The rheumatologist had more lab work done and was confused. Nothing was adding up. I still don’t know exactly what led to a whole new chain of thought pointing into a very different direction, but oddly, drinking water became a factor. The end of the story: this patient’s symptoms were due to heavy metal poisoning from the city water. Our city has really old pipes and has had known water problems. Construction had been going on for the last year and I guess water was being diverted into older pipes when other pipes had to be closed for construction. It seems what’s happening in my lil’ city from a political perspective is what happened in Flint. The water has high levels of iron and lead. As I think about our practices, heavy metal poisoning is not some typical diagnosis we will see. This isn’t even on our radar, or on any medical professional’s radar, as an immediate diagnosis.

She has maintained contact with me and she is doing much better now. She quit drinking the water. She’s fighting the fight to get the city to communicate and address the water problem. The last text that she sent me was that she went mountain biking on DTE Energy Foundation trail and felt great. For the first time in a year she felt like herself.

As I reflect on this patient and my experience with her, I think of two things: who are the appropriate candidates for pain education and what is the expected response after educating about pain?

15 responses to “When Pain Education Isn’t Enough

  1. Jessie Podolak says:

    Hi Selena,

    Thanks for sharing your case and asking some important questions about PNE:
    “Which patients are the best candidates for pain education? How soon should a change occur? How much of a change is enough to warrant a positive response to pain education?

    Your patient certainly presented as someone appropriate for PNE, with pain lasting over a year, failed treatment, and a host of circumstances that would have put her alarm system on high alert. While we don’t yet have a clinical prediction rule for who is most appropriate for PNE, we know patients with diagnoses of chronic pain, yellow flags, and/or signs of central sensitization often benefit from PNE.

    How soon should change occur? The obvious and frustrating answer is the classic “it depends.” Sometimes we see very fast change (PNE brings down threat, and once the threat has decreased, the brain no longer needs to produce pain to protect). Sometimes pain persists despite excellent education, even with patient “buy in.” In many of these cases, the pain neuromatrix has become so firmly established that it will take persistent commitment to changing not only knowledge, but also behaviors, to facilitate an “unwiring” of that particular patient’s pain neuro-signature. That is why PNE PLUS other interventions vs. PNE alone is so critical. The literature is clear that PNE in isolation does not yield the improvements in pain or other outcomes desired by both patients and clinicians.

    How much change warrants success in PNE? I would suggest that that too “depends,” this time on how you measure change. Change in knowledge? Change in pain? Change in fear? Change in function?

    As I consider your case, I would argue that perhaps PNE was a part of the successful outcome she had. She was beginning to show a good outcome in terms of her thoughts and cognitions, but the pain hadn’t changed yet (to be expected). But, the new constellation of symptoms that appeared DESPITE her grasping the concepts, asking good questions, etc., led your clinical decision making instincts to click in to high gear. When she started to take that “unexpected” turn, prompting your referral to the MD for bloodwork, the PNE didn’t lose its value…it was part of her journey towards getting her life back. We will never know how much of the success of her outcome has to do with the fact that she received good, empathetic and skilled care from YOU, learned important concepts about how pain works, and got her recovery moving in the right direction. She also had the benefit of working through her past and yellow flags with a trained mentla health provider. Even when a definitive diagnosis and treatment is ultimately discovered, our PNE intervention and therapeutic alliance with a patient can set them up to soar when other memebers of the team bring their expertise to the table.

    Thanks for the thought-provoking post!

    1. Jessie Podolak says:

      **Please forgive my double-posting! I thought the first reply got lost (drafted on my phone), and now I see it was still awaiting moderation while I wrote the second version! Also, in re-reading your post, I realize that I mis-interpreted your verbiage in terms of mental health when I wrote my first comment. I’m guessing she was NOT seeking services for that piece. Sorry about that.

      1. Selena Horner says:

        Hi Jessie,

        Thanks for taking the time to respond (twice)! She has been receiving mental health services. I’m still stuck in the “depends.” The outcome I look for in the case of persistent pain is a change in the pain presentation: reduced frequency or decreased intensity – something that indicates change. What if I didn’t pay attention? What if I blew off her increased pain as central sensitization? Do you see how the outcome could have been different? I’m not trying to be a pain, just really trying to understand so that others may appropriately apply and have a grasp at when the problem may not be central sensitization.

  2. Selena,
    This case study makes me consider the same questions. At this point, with the absence of red flags, I’ll typically use the FABQ, the 3 question depression screen, or the presence of multiple yellow flags to try to determine if a person would benefit from a pain education approach as a primary intervention. I’ll add the caveat that I typically use education about pain with all patients in varying degrees.
    I think you’re question about the expected response is one that I also don’t have a great answer for. In regard to folks whom I utilize pain education and treatments based on mitigating fear avoidance, what would general expectations look like? I would find this particularly helpful when someone asks me at eval about expected timelines to feel better and how they’ll know they’re making progress. I suspect that the immediate answer, as always, is “it depends”, but I’d love to improve my general understanding of expectations for prognosis. Looking forward to other comments and thoughts!

    1. Selena Horner says:

      Hi Chad,
      I’m happy to hear I’m not alone in trying to better understand. I’m also appreciating the comments from others.

  3. Jessie Podolak says:

    Hi Selena,

    Thanks for sharing your case and asking some important questions about PNE: “Which patients are the best candidates for pain education? How soon should a change occur? How much of a change is enough to warrant a positive response to pain education?”

    Your patient certainly presented as someone appropriate for PNE, with pain lasting over a year, failed treatment, and a host of circumstances that would have put her alarm system on high alert. While we don’t yet have a clinical prediction rule for who is the most appropriate for PNE, we know patients with diagnoses of chronic pain, with multiple yellow flags and/or signs of central sensitization often benefit from PNE. We will keep our eye out as researchers work to answer that very question with more precision.

    How soon should a change occur? The answer to that question is unfortunately the annoying answer that is so often the case: “it depends.” For some, changes in pain occur quite rapidly. Initially, a patient may even have an increase in pain (“Explain Pain Pain”), which is thought to occur when patients begin processing the information we have shared with them. Improvement in pain can happen quickly too. Since pain is a protective mechanism produced when the brain has concluded the threat is sufficient to warrant protection, information and new knowledge that decreases threat has the potential to quickly turn down pain.

    On the flip side, change in patients receiving PNE can seem exceedingly slow, even if they understand the concepts and have good “buy in.” For someone who has had pain for many months or years, their pain neuromatrix is well-established (the Hebbian Theory shows us that nerves that fire together wire together). So, PNE may result in rapid change of cognitions, but symptoms such as pain may take quite some time to decrease, as there is an “unwiring” process that must occur as patients work through the various components of their treatment plan.

    This brings up an important point as well, and it addresses the title of your post: treating a patient with ONLY PNE is not likely to bring about much change at all. The literature is pretty convincing that PNE-only treatments do not yield significant outcomes in terms of pain and function. It’s when PNE is combined with different modes of treatment, especially elements that address movement and BEHAVIOR CHANGE, that we start to see meaningful change. “PNE plus” is much more likely to result in better overall results in much less time.

    How much change warrants positive results/success? Another great question. Again (sorry), it depends. What is your measure of success? Improved knowledge about pain? Decreased pain? Increased ROM or mobility? Improved fear / avoidance? Return to work or recreational activities?

    Clinical decision making with PNE is as dynamic and skilled a process as it is with any other intervention. I would actually argue that the PNE you offered the patient in your case example may very well have played a role in her successful outcome. You screened her for red flags, recognized the yellow flags and the qualities that made her appropriate for PNE, and set out in a very logical direction. What’s great is that she “bought in,” as evidenced by her good questions/participation, which led you to conclude that her symptoms should move in a positive (albeit potentially slow) direction. When her symptoms moved in the OPPOSITE direction, your clinical decision-making instincts told you something else may be going on, prompting your referral for bloodwork.

    The PNE she received was no waste of time. True, it wasn’t “enough” for her to result in complete resolution of symptoms, but the part of her journey involving PNE may have “primed the pump” for the intervention by the rheumatologist to take a firm hold and yield a great outcome. Clearly, she had a good experience with you: she gained knowledge, and a solid therapeutic alliance was forged. The trust, the confidence that she was in good hands…all of that very likely helped calm her system down, even in the presence of the metal poisoning. It’s a bummer that we will never know what percentage of her healing was the result of your intervention vs. the further work done by other members of her health care team, but I will put my money on PNE having played some role in the good outcome she is enjoying.

    Thanks again for the thought and discussion-provoking questions

  4. Kory Zimney says:


    I don’t think PNE is meant to guide clinical reasoning and decision making. PNE is an educational strategy to help patients understand the complexities of a pain experience through the use of various metaphors and examples to reduce threat and help them change behaviors related to fear, anxiety, and catastrophization mostly related to movement to allow them to function better. I think Mark Jones has given us a very good definition of clinical reasoning: “Application of relevant knowledge (information, procedures and concepts) and clinical skills to patient management on an individual level.” PNE and clinical reasoning are two very separate things based on my understanding of what each of them are. Pain science understanding should never be used in isolation to guide clinical reasoning, no individual science understanding should be used in isoloation. Pain science along with a multitude of other sciences (biology, anatomy, biomechanics, pathophysiology, psychology, sociology, etc.) should help guide our clinical reasoning process.

    I think you provided a very interesting case study to the importance of ongoing assessment. The aphorism coined by Dr. Woodward, “When you hear hoofbeats, think of horses not zebras”, is usually a good principle to follow. In this specific case there was a zebra. As clinicians we need to strive, as you did, to stay alert for possible zebras when the patient does not respond as we would anticipate.

    In regards to your questions that you posed I would respond with the following:

    “who are the appropriate candidates for pain education” – anyone that we clinically reason may benefit from understanding pain better to help reduce fear, anxiety, and/or catastrophization behaviors due to inaccurate understandings of their pain experience which may be lead to maladaptive responses to their threat analysis of pain and movement.

    “what is the expected response after educating about pain” – research shows us that the NNT for pain is 1 in 3, and function 1 in 2. It is not an end-all-be-all treatment meant to fix everything, and always needs to be used with active movement and never in isolation. These improvements are typically no effect or small to moderate effect sizes in large scale studies, but individual responses are variably from no response to dramatically large effects. The good news is no significant bodily harm can be done through an educational strategy compared to a physical or pharmacological intervention which can have positive but also negative health effects and usually provide similar effect sizes. The recipient should have an increase in pain knowledge after receiving PNE and potentially improved pain and/or function along with decrease in healthcare utilization based on the evidence to this point in time.

    1. Selena Horner says:

      Hi Kory,
      Thanks for commenting.
      Maybe I am misunderstanding the reason for pain education. From my interpretation, pain education should impact the brain and change the patient’s internal interpretation/perception. The outward observation would be a reduction in pain experience and improved function.
      I believe that in this particular example, if I interpreted the situation as being an increase in central sensitization, more harm would have been done. That is what led me to share this experience.
      I do expect patient’s to change. I do expect to be able to notice the change. I also believe that I should have some sort of time frame of the expected amount of change. If I don’t have some sort of expectation in my head, then I don’t quite have a game plan of knowing that I need to change tactics or interventions or reassess the situation. Does that make sense?

      1. Kory Zimney says:

        Yes, that makes sense. If we are not seeing expected changes then we should be considering other alternatives.

  5. Gregory Pfeiffer says:

    The aphorism coined by Dr. Woodward, “When you hear hoofbeats, think of horses not zebras”, is usually a good principle to follow.

    I think that is a terrible “principle” to follow and leads to shortcuts, incomplete assessment and a shoddy diagnostic process!

    1. Selena Horner says:

      Hi Gregory,
      Thanks for sharing. I do typically think horses because realistically it is horses. The biggest issue for me – when to bail on thinking it’s a horse and switching gears to wonder if zebra. Knowing time frames helps with clinical decision making for me. Does that make sense?

  6. Kory Zimney says:

    I don’t think the principle is meant as an excuse to provide incomplete assessments, instead to caution us from potential waste of over evaluating and treating.

  7. Brian D'Orazio DPT, MS, OCS says:


    What caused your ” alarm bells ” to go off? An amazing call on your part from all perspectives. First, you strongly considered that your patient’s pain may have a bio-psycho-social component…which frankly places you many steps ahead of most clinicians in any field. Second, you recognized the additional symptoms as a change in her complaint and by the 4th visit you were concerned. That’s really early in the diagnosis/treatment strategy, so there must have been something about the patient or her presentation that created the concern. ( sorry to be so late in this discussion, but this is one of the most interesting posts I’ve read ). Thanks for sharing and I look forward to your reply.


    1. Selena Horner says:

      Hi Brian, sorry for my really, really late reply. I first really thought her pain was related to biopsychosocial factors given all the psychosocial information she shared. During her 3rd visit, I was really surprised by her knee pain as I was doing a manual technique. This wasn’t fitting a typical response for someone with ongoing back pain. She had already had quite a bit of chiropractic care. The other aspect: her age. She isn’t an older patient: she’s young. The other aspect: her facial expressions and her eyes. I value nonverbal components. Her eyes were filled with not just fear, but pain. Her facial expression I can’t say showed pain, but concern. I don’t really know how to explain it. The other nonverbal was her body movements: she was a squirmer. She was always changing position and wiggling around a bit: very small motions, but she just couldn’t stay completely still due to her level of discomfort.
      The alarm really clanged on her 4th visit. I guess I have a bit of confidence in what I do. With what I provided and what she was to work on after her 3rd visit, my expectation was a 50% reduction in her symptoms. This didn’t happen: she had pain in other joints and increasing level of fatigue. I know pain can contribute to fatigue level… the level she described was not what would be typical.
      With every patient, my first and foremost focus is to answer this question: is this patient a candidate for physical therapy services? Every visit my brain focuses on that question. For this patient, when she returned on the 4th visit and shared her response to the 3rd visit and her home exercise program, the answer to my question was “maybe not.” At that point, I dig further into a patient’s history to see if I can piece together an explanation versus assuming biopyschosocial.

      Thanks for allowing me to reflect deeper, Brian.

  8. catchy says:

    i agree with what you say

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