PNE: Right Message, Wrong Door

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?







7 responses to “PNE: Right Message, Wrong Door

  1. Keith Roper says:

    Jarrod, this is a thoughtful and clinically relevant essay. I have also made many errors of judgement in incorporating PNE into my practice and continue to learn how to more effectively weave it into my patient interactions.

    I love your comment about pain being “of the brain, not in the brain”. Language matters very much and I tread very carefully around this idea, but find that if I use a whole person explanation rather than “blaming” a specific system or organ, patients are much more receptive and understanding.

    Thanks for this great analogy, it is a useful way to think as we explore patient experience and belief, and will hopefully help improve our success at opening the right doors…

    1. Jarrod says:

      Thanks for reading and the comments Keith. You are spot on recognizing the importance of language and what we say matters so much… Keep up the good work!


  2. Love your commentary Jarrod. What are some references that you recommend topatients? Do you send them home with any custom printed material that you have developed within your clinic?
    Your commentary on changing beliefs is spot on, and far too often we attempt to insert our values in to a patient’s hard wired belief systemwide soon. The ” I need an MRI” statement is one belief we all hear voiced, and it is often difficult to explain to a chronic pain patient why PT should come first. Countless other examples, but where should a young PT go, in your opinion for some valuable con Ed on the subject?

  3. Jarrod Brian says:

    Thanks for reading and your comments. Great questions…
    In the clinic I often us the Why You Hurt: Pain Neuroscience Education Box by Adriaan Louw. Our clinic purchased one over 2 years ago and we use it often.
    Though you can get good at PNE without the Why You Hurt Box. You can always dig into research papers on PNE.
    For Con Ed courses, the International Spine and Pain institute offers many classes that will help you take on pain with a modern approach. ( Of course going even deeper is ISPI’s Therapeutic Pain Specialist program.

    Any of these are great options. Let me know if you have any other questions and don’t hesitate to contact me further at [email protected]

    Keep learning, you are on the right track!


  4. Paul Leverson says:

    Your metaphors of “many doors” is a great one, and, I believe one that should be shared with the patients so they can understand why, in one case, they are more successful treating their own pain and, in another, they are not as successful.
    …wrong door = wrong belief on “Why I hurt.”

    Pain is an opportunity to exercise…not physically…mentally. It’s a challenge for the pt to look at why they are hurting, understanding pain at a deeper level, not fearing or ignoring it, rather, constructively confronting it. This requires fear is addressed. One way to do this is to work hard initially at giving the pt leverage over pain. Techniques or treatments that can help this immediate bout of pain starts to de-tooth the lion of pain. It also gives time for the PT to build rapport and a positive alliance with the pt so they are more willing to believe the truth about pain.

    I really appreciate your metaphor. Plan to use it with my patients to help them treat their own pain.

    Thanks a bunch.

    1. Jarrod says:

      Thanks for the comments Paul. Much appreciated!


  5. Phil Gainan says:

    Very interesting article. Pain (chronic pain) has so many layers. As a PT, as well as D,C, I have found through the years that for various reasons the pain the patient presents gives them the reason, belief that they can some how check out. They don’t have to be present. In other words, some patients can live on the sidelines of life. For some it may be the attention, for others perhaps ; gives excuse to not have to work, help.

Leave a Reply

Your email address will not be published. Required fields are marked *