Pain Neuroscience Education (PNE): Difference between revisions

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'''Original Editor '''- [[User:David Greaves|David Greaves]], [[User:Lynette Fox|Lynette Fox]], and [[User:Katie White|Katie White]] as part of the [[Nottingham University Spinal Rehabilitation Project]]


==== &nbsp;What is Pain Neuroscience Education (PNE)?  ====
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp; <br>
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Pain Neuroscience education (PNE) consists of educational sessions for patients describing in detail the neurobiology and neurophysiology of pain and pain processing by the nervous system (Louw et al., 2011). This educational approach has been used by physiotherapists therapeutically since 2002 in various countries including the UK, US and Australia and differs considerably from traditional education strategies such as back school and biomechanical models (find reference). This is due to how likelihood of pain chronicity (e.g. for an MSK condition) may not likely be caused by unhealthy or dysfunctional tissues but brain plasticity leading to hyper-excitability of the central nervous system, known as central sensitisation (Nijs et al., 2015). Therefore, a deeper level reasoning and treatments beyond a medical model is required.  
== Introduction  ==
[[File:PNE.webp|right|frameless|234x234px]]
Chronic pain is defined as pain that lasts more than three months. It is a very common and prevalent problem that affects most age groups worldwide. Chronic pain is a multifactorial disorder that is influenced by biology, psychology, environmental, and social factors.<ref>Mills SEE, Nicolson KP, Smith BH. Chronic pain: a review of its epidemiology and associated factors in population-based studies. Br J Anaesth. 2019 Aug;123(2):e273-e283.</ref> Pain Neuroscience Education (PNE) is a strategy that aims to teach patients to reshape their mindset and perception of [[Pain Behaviours|pain]] despite these factors. It provides patients a better understanding of their condition and motivates them to become active participants in their treatment programs.


[[Image:Back pain 1 resized.jpg|center|300x200px]]<br>  
Based on a large number of high-quality studies, it has been shown that teaching people with chronic pain more about the neuroscience of their pain produces immediate and long-term changes. PNE has been shown to have positive effects in reducing pain, disability, and psychosocial problems, improving patient's knowledge of pain mechanisms, facilitating movement and decreasing healthcare consumption.<ref>Zimney KJ, Louw A, Cox T, Puentedura EJ, Diener I. Pain neuroscience education: Which pain neuroscience education metaphor worked best?. South African Journal of Physiotherapy. 2019 Jan 1;75(1):1-7. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6739553/<nowiki/>(accessed 19.4.2022)</ref>  


Initially, PNE changes a patient’s perception of pain. For example, a patient may have believed that damaged tissues were the main cause for their pain, and by receiving education about pain neurophysiology the patient understands that pain may not correctly represent the health of the tissue, but may be due to extra-sensitive nerves. As a result, patients have been found to have a reduction in fear avoidance behaviours and are more able and willing to move. PNE can be used with a combination of treatments, including exercise therapy that can be used to break down movement-related pain memories with graded exposure to exercise and decrease sensitivity of the nervous system (Nijs et al., 2015).<br>
== Pain Neuroscience Education (PNE) ==


==== What does PNE consist of / involve?  ====
With respect to PNE, [[Chronic Pain and the Brain|chronic pain]] is not viewed as a result of unhealthy or dysfunctional tissues. Rather, it is due to [[Neuroplasticity|brain plasticity]] leading to hyper-excitability of the central nervous system, known as central sensitization.<ref name=":1">Nijs J, Girbés EL, Lundberg M, Malfliet A, Sterling M.  Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories. Manual therapy. 2015; 20 (1): 216-220.</ref> The ultimate goal for Pain Neuroscience Education (PNE) is to increase pain tolerance with movement (e.g., be able to perform exercise with mild discomfort), reduce any fear associated with movement, and reduce central nervous system hypersensitivity. In practice, this often includes the use of educational pain analogies, re-education of patient misconceptions regarding disease pathogenesis, and guidance about lifestyle and movements modifications that can be introduced.


PNE first of all puts the complex process of describing the nerves and brain into a format that is easy to understand for everyone; no matter whether the target audience is of a particular age, educational level or ethnic group. This is made possible by using simplified scientific language used with additional methods of presenting information that may include the use of:<br>• Simple pictures<br>• Examples<br>• Booklets<br>• Metaphors<br>• Drawings<br>• Workbook with reading/question-answer assignments<br>• Neurophysiology Pain Questionnaires
There are two clinical indications for initiating Pain Neuroscience Education (PNE)<ref name=":2">Nijs, J., Paul van Wilgen, C., Van Oosterwijck, J., van Ittersum, M., Meeus, M.,How to explain central sensitization to patients with ‘unexplained’ chronic musculoskeletal pain: Practice guidelines, Manual Therapy, 2011, 16:5, 413-418</ref>:


Methods of PNE delivery vary but can typically involve around 4 hours of teaching that is provided to a group or individually, either in single or multiple sessions (Clarke et al., 2011).  
* the clinical picture is dominated by central sensitization
* illness coping mechanisms or poor illness perception is present
[[Image:Effects_of_central_sensatisation.png|313x313px|alt=|thumb|Effects of central sensitization]]


(Louw et al., 2011) states the content of PNE education sessions with patients in 4 studies consisted of:<br>• Neurophysiology of pain<br>• Nociception and nociceptive pathways<br>• Neurons<br>• Synapses<br>• Action potential<br>• Spinal inhibition and facilitation<br>• Peripheral sensitization<br>• Central sensitization<br>• Plasticity of the nervous system<br>  
Central sensitization is when there is amplification of pain in the central nervous system. It can result in hypersensitivity to stimuli, responsiveness to non-noxious stimuli, and increased pain response evoked by stimuli outside the area of injury, an expanded receptive field. <ref>[[Central Sensitisation]]</ref>This can be assessed during the subjective and objective portion of a patient's evaluation. A physical therapist can determine what a patient's perception of their own pain is and how they cope with their pain. [[File:Upload_version_of_systemic_effects.jpg|alt=|thumb|426x426px|Pain behaviors caused by central sensitization]]PNE aims to reconceptualize pain to patients with these four main points:
* Pain does not provide a measure of the state of the tissues
* Pain is modulated by many factors from somatic, psychological, and social domains
* The relationship between pain and the state of tissues becomes less predictable as pain persists
* Pain can be conceptualized as the conscious correlate of the implicit perception that tissue is in danger<ref name=":0">Moseley GL. Reconceptualising pain according to modern pain science. Physical therapy reviews. 2007 Sep 1;12(3):169-78.</ref>


==== How is PNE&nbsp;used in clinical practice? ====
== Application of PNE  ==
The application of PNE is most useful as part of a combination therapy for chronic pain that includes physiotherapy intervention (including [[Therapeutic Exercise|exercise therapy]])  and may or may not include [[Pain Medications|pharmacological treatment]]. Its application is best applied by trained and skilled clinicians with experience in managing patients with chronic pain conditions. Overall, PNE serves as a method of reconceptualizing a patient's perception of their pain experience, providing an avenue for reducing pain, disability and improving [[Quality of Life|quality of life]]<ref name=":0" />. PNE puts the complex process of describing the nerves and brain into a format that is easy to understand for everyone regardless of age, educational level, or ethnic group.<ref name=":10">Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of physical medicine and rehabilitation. 2011; 92(12):2041-2056.</ref>{{#ev:youtube|?v=6RGP_usIbBU|width}}<ref>Pain Neuroscience Education PAINWeek
Available:https://www.youtube.com/watch?v=6RGP_usIbBU (accessed 19.4.2022)</ref>


Below is an example of how a story / metaphor used by Louw et al., 2011 is used in clinical practice to teach patients about complex pain physiology including extra-sensitive nerves, inflammation, injury and made how pain is created in the brain. It is such an example that helps patient to break away from a view of a particular tissue being the issue (e.g. generative disc) and helps the patient think towards the problem being related to pain and a sensitive nervous system (Louw et al., 2011). Therefore, Instead of pain following spinal surgery being seen as the ‘problem has not resolved’ or ‘there is something still wrong with the disc’, PNE would explain pain is sensitive to act as a protector which is perfectly normal after surgery. <br>
Methods of PNE delivery vary but can typically involve around 4 hours of teaching that is provided to a group or individually, either in single or multiple sessions.<ref name=":4">Clarke CL, Ryan CG, Martin DJ. Pain neurophysiology education for the management of individuals with chronic low back pain: A systematic review and meta-analysis. Manual therapy. 2011; 16(6):544-549.</ref>PNE consists of educational sessions for patients describing in detail the neurobiology and neurophysiology of pain and [[Pain Facilitation and Inhibition|pain processing]] by the [[Introduction to Neuroanatomy|nervous system]].<ref name=":10" /> It is implemented prior to administering physical therapy interventions with a verbal explanation. This is subsequently reinforced throughout the course of treatment to ensure proper carryover of reconceptualization of pain during and after discharge from physical therapy.  


'''Scenario of PNE used in clinical practice:'''<br>Suzy is experiencing pain and believes her pain is due to a bad disc. However, the pain has been there for 10 years. It is well established that discs reabsorb between 7-9 months and completely heal. So, why would it still hurt? She believes (as she has been told by clinicians) that her pain is caused by a bad disc. Now, we start explaining complex pain issues via a story/metaphor with the aim to change her beliefs, and then we set a treatment plan in place based on the new, more accurate neuroscience view of pain.<br>  
During the first educational session, the clinician should explain central sensitization along with the use any of the following: pictures, booklets, pamphlets, metaphors, drawings, question/answer assignments, and neurophysiology pain questionnaires. Topics addressed include acute pain vs. chronic pain, how it evolves from acute pain to chronic pain, interpretation of stimuli to the nervous system, and external factors that may impact pain (such as anxiety, stress, depression, pain perceptions, and behavior). Patients are encouraged to read the handouts or brochures handed to them from the clinician at home.<ref name=":2" />


Therapist: “If you stepped on a rusted nail right now, would you want to know about it?”<br>  
During subsequent sessions, the patient is encouraged to ask questions and receive clarification for any questions they may have about the neurophysiology of their pain. The clinician can address psychosocial aspects of a patient's pain during any visit. Some examples of clinically indicated advice that can be provided include advising the patient to stop worrying about their pain, reduce stress, implement relaxation techniques, and become more physically active. The treatment rationale should be provided throughout the patient's plan of care. Continually reinforcing and educating the patient regarding their pain physiology is recommended. The overarching goal is to motivate and encourage the patient to complete their treatment program in order to achieve their functional goals. <ref name=":2" />  


Patient: “Of course.”<br>  
Figure 4. illustrates the content of PNE education sessions with patients<ref name=":10" />  


Therapist: “Why?”<br>
[[Image:Methods of PNE.jpg|center|Figure 4. displays the content of PNE education sessions|alt=Figure showing the content of PNE education sessions|369x369px]]


Patient: “Well; to take the nail out of my foot and get a tetanus shot.”<br>
An example of a metaphor or story that can be used with patients is provided here: http://www.instituteforchronicpain.org/treating-common-pain/what-is-pain-management/therapeutic-neuroscience-education.


Therapist: “Exactly. Now, how do you know there’s a nail in your foot? How does the nail get your attention?”<br>  
=== PNE for Chronic Musculoskeletal Conditions<ref name=":13">Moseley GL, Butler DS. Fifteen years of explaining pain: the past, present, and future. The Journal of Pain. 2015;16(9):807-813.</ref> ===
[[Image:Chronic MSK conditions.jpg|alt=|thumb|Chronic MSK&nbsp;conditions with positive PNE results |301x301px]]These conditions are often characterised by brain plasticity that leads to hyperexcitability of the central nervous system (central sensitisation). Figure 5 highlights chronic musculoskeletal conditions that benefit from PNE, including osteoarthritis, fibromyalgia, pelvic pain, whiplash, lateral epicondylitis, and low back pain.<ref name=":6">Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up. Spine. 2014; 39(18):1449-1457.</ref><ref name=":7">Zimney K, Louw A, Puentedura EJ. Use of Therapeutic Neuroscience Education to address psychosocial factors associated with acute low back pain: a case report. Physiotherapy theory and practice. 2014; 30(3):202-209.</ref>


Therapist: “The human body contains over 400 nerves that, if strung together, would stretch 45 miles. All of these nerves have a little bit of electricity in them. This shows you’re alive. Does this make sense?”<br>  
Recent studies suggest that PNE in conjunction with either therapeutic exercise or manual therapy yielded significant reduction in pain ratings.<ref>Louw, A., Zimney, K., Puentedura, E., Diener, I., The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature, Physiotherapy Theory and Practice, 2016, 32:5, 332-355.</ref>


Patient: “Yes.”<br>


Therapist: “The nerves in your foot are always buzzing with a little bit of electricity in them. This is normal and shows….?”<br>


Patient: “I’m alive.”<br>  
== References ==
<references />  


Therapist: “Yes. Now, once you step on the nail, the alarm system is activated. Once the alarm’s threshold is met, the alarm goes off, sending a danger message from your foot to your spinal cord and then on to the brain. Once the brain gets the danger message, the brain may produce pain. The pain stops you in your tracks, and you look at your foot to take care of the issue. Does this sound right?”<br>
 
 
[[Category:Nottingham University Spinal Rehabilitation Project]]
Patient: “Yes.”<br>
[[Category:Lumbar Spine]]  
 
[[Category:Lumbar Spine - Interventions]]  
Therapist: “Once we remove the nail, the alarm system should…?”<br>
[[Category:Interventions]]
 
[[Category:Pain]]
Patient: “Go down.”<br>
 
Therapist: “Exactly. Over the next few days, the alarm system will calm down to its original level, so you will still feel your foot for a day or two. This is normal and expected."<br>
 
Therapist: “Here’s the important part. In one in four people, the alarm system will activate after an injury or stressful time, but never calm down to the original resting level. It remains extra sensitive. With the alarm system extra sensitive and close to the “firing level,” it does not take a lot of movement, stress or activity to activate the alarm system. When this happens, surely you think something MUST be wrong. Based on your examination today, I believe a large part of your pain is due to an extra-sensitive alarm system. So, instead of focusing of fixing tissues, we will work on a variety of strategies to help calm down your alarm system, which will steadily help you move more, experience less pain and return to previous function."<br>
 
==== Indicators for the use of PNE  ====
 
Low Back Pain<br>Low back pain (LBP) is currently considered to be the most common cause of disability and time off work in the over 45 age group, with it being reported that 84% people will experience LBP at some point during their life (Balagué et al., 2012). Whilst LBP is generally considered a self-limiting condition it can have severe implications to the patient’s psychological and physical health. Results from a UK survey, analysing the consultation prevalence for LBP showed that 417 per 10 000 registered patients sought medical help for their LBP, with the highest numbers being seen in the 45- 64 age group (536 per 10 000) (Jordan et al., 2010). Furthermore an Australian cohort study discovered whilst most patient’s recovered 1/3 had not fully recovered after 1 year (Henschke et al., 2008). LBP is clearly a substantial problem for both the health system and the socioeconomic environment, thus effective management is critical.<br>Updated NICE guidelines for Chronic LBP states that information and self-care advice should be provided to patients to promote self-management by fostering a positive attitude and providing realistic expectations to patients. However the type, duration, frequency and content of this advice was not reported on (NICE, 2015).<br>
 
==== The benefits and drawbacks of PNE  ====
 
<span style="font-size: 13.28px; line-height: 1.5em;">Table showing the benefits and drawbacks of PNE</span>
 
{| width="200" border="1" cellpadding="1" cellspacing="1"
|-
| Benefits
| Drawbacks
|-
| RCT's have shown a reduction in fear and catastrophizing, due to the immediate effect of PNE on improving attitudes and beliefs about pain.
| Evidence suggests PNE alone is not a viable intervention for pain and disability
|-
| Positive effect on disability and physical performance
| Provides concerns regarding healthcare cost
|-
| Increased pain thresholds during physical tasks
| Less availability of such specialized education to patients in remote regions
|-
| Improved adherence and outcomes of therapeutic exercises
| "in clinic" attendance issues arise for patients with time and financial constraints
|-
| May reconceptualise the patients' beliefs on physiotherapy
| Clinicians need to be trained in PNE competencies
|-
| Improved passive and active range of motion
| Long term effects are not as significant as short term
|-
| No harmful effects
| Future research required on the notion of individual and group curricula; e.g. what is taught, how it is taught and measured
|}
 
<br>
 
<br>
 
==== '''Brain activity clinical imaging of PNE effect'''  ====
 
There are various types of brain imaging including those pictured below:
 
[[Image:PET, MRS and fMRI.png]]  
 
Figure&nbsp;?. Pictured left to right are Positron emission tomography (PET), magnetic resonance spectroscopy (MRS) and&nbsp;functional magnetic resonance imaging (fMRI) of pain.&nbsp;(Sharma, Brooks, Popescu et al., 2012; Cole, Farrell, Duff et al., 2006; Casey, Morrow, Lorenz et al., 2001).
 
Effects of therapeutic neuroscience education<br>By teaching a patient more about how pain works with reassurance that pain doesn’t always mean tissue damage, their pain eases considerably and they experience other benefits including increased movement, better function and reduced fear avoidance. These effects are measurable via brain imaging as demonstrated below:
 
A high-level dancer experiencing significant back pain for almost two years who was scheduled for back surgery in two days was scanned using fMRI. Areas of brain activity related to pain are demarcated in red.
 
Row 1: Patient relaxing. Note no red areas. <br>[[Image:FMRI row 1.png]]<br>
 
<br>
 
Row 2: Patient was asked her to move her painful back while in scanner. These images demonstrated brain activity related to pain whereby larger areas of red signifies more pain.
 
[[Image:FMRI row 2.png]]<br>
 
<br>
 
Row 3: After initial scans the patient taken out of the scanner and provided with a teaching session of 20-25 minutes about pain. The scan of the patient was immediately repeated doing the same painful task as performed in Row 2. Note this time, however, there is significantly less activity (fewer red areas), while doing the same painful task as before.<br>
 
[[Image:FMRI row 3.png]]<br>
 
(Louw A, et. al 2014 – submitted for publication)
 
There is an obvious link in attention to pain that when negatively perceived, impacts on the experience of pain being greater. One study by Cole, Farrell and Duff et al., (2006) demonstrated that pain related brain activity was greater in pts with Alzheimer’s, than age matched healthy controls. However, in this population there is less reporting of pain and analgesic use. Is this due to difficulty to communicate pain or due to reduced attention to pain?
 
==== Training / education of therapists to use it  ====
 
==== History of pain models and devlopment of PNE  ====
 
'''Where has PNE developed from?'''<br>The biomedical model is most commonly used by physiotherapists and other medical health professionals for the management of pain (Louw, 2014 &amp; Linton, 2005). The model follows that pain and injury interrelated, thus an increase in pain means further tissue damage have occurred (Louw, 2014) and vice-versa. This model, called the Cartesian model, is over 450 years old, and many argue inaccurate and significantly outdated (Louw, 2014).
 
'''Cartesian Model'''[[Image:Rene Descartes.jpg|thumb|: Cartesian theory of pain that states that pain to the brain is a “straight line”]]  
<div>The Cartesian ‘mid-body’ was first&nbsp;proposed in the early 16th Century by the French Philosopher, Mathematician and Scientist Rene&nbsp;Descartes, in an attempt to show that humans were a mechanical body controlled by a rational soul (Linton, 2005). Descartes model proposed that the brain was the centre of senses, receiving hollow nerve tubes through which free spirits flowed. Nerves were connected to the brain as a piece of rope may be connected to an alarm; thus as pulling of the rope would cause the alarm to sound, injury caused a mechanical-like rope to be pulled, activating a bell in the individuals mind (Linton, 2005). Descartes therefore considered there was a direct correlation between the extent of tissue damage and pain experienced, the greater the extent of damage the more intense the pain experienced (Linton, 2005) </div>
'''Why is the model considered outdated?'''<br>Descartes model continues to be used in current medical practice and influences the perception that all pain is a result of injury and tissue damage (Linton, 2005). Clinicians frequently use<span style="line-height: 1.5em; font-size: 13.28px;">&nbsp;the biological model to explain patient’s pain, describing pain as being due to either disc, joint or abnormal movement pattern (Louw, 2014). The resulting treatment is therefore focused on addressing the abnormal movement pattern or faulty tissue, and the pain goes away. However research has shown that education using words such as “bulging”, “herniated” and “ruptured” actually increases patient's levels of fear and anxiety, resulting in protected movements and lack of exercise compliance (Louw, 2014).
</span>
 
<br>
 
However Descartes biomedical model has been questioned in recent years, with critics arguing that it fails to consider the perception of pain from the nervous system, as well as the psychological and social factors that may influence recovery (Linton, 2005). Furthermore both psychiatrists and behavioural scientists have highlighted specific medical examples to further question the validity of Descartes model. The examples below suggest that pain may potentially be a phenomenon more than just nociception, and may have a neurological element:
 
*Pain was not expressed by a soldier injured in war until reaching the hospital (Goldberg, 2008)
*Similar injuries in different patients caused substantially different pain responses (Goldberg, 2008)
*An incision to the skin twice as deep as that of another, does not hurt twice as much (Goldberg, 2008)
*Why 40% of &nbsp;people with horrific injuries felt either no or a low intensity of pain (Melzack, Wall &amp; Ty. 1982)
*Why up to 70% of people's do not report pain or associated symptoms consistent with their X-ray/ MRI finding (Bhattacharyya et al., 2003; Boden et al., 1990)
*Why 51% of amputees reported phantom pain and 76% phantom sensations including: cold, electric sensations and movement in the phantom limb (Kooijmana, 2000).
 
Furthermore in Beecher’s (1956) comparison study of 150 male civilian patients in contrast to wartime casualties, it was discovered that 83% in the civilian group requested narcotics, whilst only 32% of military patients with the same extent of tissue damage asked for them; thereby suggesting the level of pain experienced is patient dependant. &nbsp;In this example it was proposed the patient's emotions, beliefs and experiences of pain altered the brains interpretation of the pain, resulting in different intensities of pain being experienced.
 
'''The Pain-neuroscience education model'''<br>In the last century Descartes biomedical model has been replaced by the biopsychosocial model of chronic pain (Goldberg, 2008), in which pain is classified as being due to increased sensitivity of the nervous system rather than further injury (Louw, 2014). In layman’s terms, pain persists after tissue healing, due to the fact that the body’s alarm system remains activated, and are stimulated by a much lower intensity of stimulus (Louw, 2014); i.e. a much lower degree of movement provocation causes pain.
 
<br>'''How does this affect clinicians in practice?'''
 
Investigations by the Therapeutic Neuroscience research team at the ‘International Spine and Pain Institute’ has discovered that people in pain are interested in pain and more specifically the mechanisms of pain (Louw, Louw &amp; Crous, 2009). Thus current treatment for patients with chronic pain should have a greater focus on educating patients about the neuroscience of their pain, rather than classifying their pain as being due to faulty movement patterns or damaged tissues. <br>
 
<br>
 
==== Section 1 – Scenarios to aid learning and clinical relevance:  ====
 
<br>
 
==== Patient's experiences of Low Back Pain  ====
 
{{#ev:youtube|a9f6VJtls2E}}<br>
 
==== Diagram of alarm systems (can be a hand drawn and in a simple video format with narration or just images with text)  ====
 
====  ====
 
<br>
 
{{#ev:youtube|hxTkm_YqJbs}}
 
<br>
 
==== Section 3 – Evidence  ====
 
====  ====
 
'''Paper 1:'''<br>
 
A recent systematic review investigating the effects of pain neuroscience education (PNE) on pain, disability and anxiety, discovered that PNE was an effective therapeutic tool for patients with chronic musculoskeletal pain. Although the review searched all major databases over a 10 year period, only 8 studies (6 RCT’s, 1 pseudo-RCT and 1 comparative study) satisfied the inclusion criteria and were included in the review. The methodological quality of these studies was assessed using the Critical Review Form–Quantitative Studies criteria and the CONSORT checklist, with all included studies deemed to have either good, very good or excellent quality. The review included 401 patients, finding that PNE was significantly more effective at decreasing pain (P&lt;0.01), pain catastrophization (P&lt; 0.001) and perceived disability (P&lt;0.01) compared to the control group (receiving only ongoing medical care), in both the short-term and long-term. Furthermore both one-on-one and group sessions significantly decreased pain and disability (P&lt;0.05), however one-to-one sessions were found to be the more favourable delivery method (P&lt;0.004). Nevertheless results from the review failed to discover the most effective frequency and duration of PNE sessions, with RCT’s reporting sessions lasting for 30minutes to 4 hours, with either a single sessions or multiple sessions being reported effective by clinicians. Moreover the review considered all types of chronic musculoskeletal pain including: Whiplash, Chronic Fatigue syndrome, widespread pain and Chronic Low Back Pain (LBP), thus may lack the generalisability to this article considering PNE for the treatment of LBP.<br>
 
'''Paper 2:'''
 
Compared to the previous systematic review’s poor generalisability of PNE for a range of chronic pain conditions, researchers in this multi-centred randomised control trial focused solely on Preoperative Pain Neuroscience Education for Lumbar Radiculopathy by Louw et al., (2014).
 
This study involved 7 sites in the United States (US) and a sample of patients awaiting lumbar surgery for radiculopathy with follow-up over a year. An exclusion criteria was justified to avoid variables in the population (e.g. other chronic pain conditions). Primary outcomes consisted of pain, leg pain and function. Secondary outcomes comprised of experience of lumbar surgery (5 x 1 – 10 Likert scale questions) and health utilisation (questionnaire). 67 patients were randomised to one of two groups: usual care (preoperative education) and experimental group (usual care and PNE preoperatively). Results found that at 1-year follow-up there were no statistical differences in primary outcomes. However, there were significant statistical differences in favour of the PNE group across all secondary outcomes; with patients feeling better prepared for surgery (p&lt;0.001), preoperative session preparing them for surgery (p&lt;0.001) and surgery meeting their expectations (P&lt;0.021). Also, reduced health utilisation in PNE group (p=0.007), resulting in 45% less health expenditure compared to usual care group.
 
The internal validity of the study is positive with measures in place to reduce risk of bias where possible. Methodological quality could have only improved through blinding but is not appropriate for the groups. The study scored a Pedro scale of 8/11. The secondary outcomes improving patient experiences after surgery and health utilisation are hugely clinically relevant, especially in relation to the financial challenges of National Health Service (NHS) in the UK. Any reduction in services post-surgery and thus reducing costs, whilst additionally improving patient experiences with minimal cost to implement cannot be overlooked. However, the UK’s NHS and health insurance systems in the US will differ dramatically in relation to resources available and how often treatments can be accessed. Subsequently, this study did not control the amount of rehabilitation patients were allowed to access, which could further skew results of outcomes, especially compared to the UK where amount of rehabilitation will be determined by post-operative protocol. Finally, the generalisability of the findings to another type of surgery, e.g. spinal fusion, must be applied with caution despite promising outcomes due to the specificity of the results to surgery for radiculopathy. <br>
 
'''Paper 3:'''
 
With regard to the concerns of generalising the results from the previous RCT to non-specific low back pain patients, a systematic review and meta-analysis by Clarke, Ryan and Martin 2011, investigated the impact of PNE, specifically on that management of patients with chronic low back pain.
 
Outcome measures included pain, physical-function, psychological function and social function. The characteristics of the subjects were adults (≥ 18 year) in which at least 50% of the patients had non-specific CLBP. Trials with possible serious spinal pathology were excluded.&nbsp;Two moderate quality RCT’s were included. The meta-analysis found PNE produced statistically significant but clinically small improvements in short-term pain. The reviewers found improvements in all other outcomes but they were not clinically significant, so therefore, due to this and the small number of studies, clinical recommendations cannot be made until further research<br>The limitations of this review, as critically appraised using the JBI checklist, were the small number of studies included in the review and furthermore, both studies included were published by one of the co-authors of the PNE manual, so there is a potential conflict of interest. There also could have been a wider range of resources used to search for studies as only 3 databases were observed. <br>
 
However, the critical appraisal of the papers selected was independently assessed by 2 reviewers, minimising bias and each RCT was assessed using the Cochrane back review group (CBRG) guidelines.Contrary to the previous systematic review by Louw and Butler 2011 which focused on a range of chronic conditions, this review is specific to CLBP which make it more generalizable. Lastly the implications for practice and research were based primarily on the reported data.<br><br>
 
'''Paper 4:'''
 
<br>
 
==== Clinical bottom line:  ====
 
==== Referances:  ====
 
1. Beecher HK. (1956). The frequency of pain severe enough to require a narcotic was studied in 150 male civilian patients and contrasted with similar data from a study of wartime casualties. Efforts were made to have the. Journal of the American Medical Association. 161 (17), 1609-13.<br>2. Bhattacharyya T, Gale D, Dewire P, Totterman S, Gale ME, McLaughlin S, Einhorn TA, Felson DT. (2003). The clinical importance of meniscal tears demonstrated by magnetic resonance imaging in osteoarthritis of the knee. Journal of Bone and Joint Surgery American volume. 85-A (1), 4-9.<br>3. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. (1990). Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation.. Journal of Bone and Joint Surgery American volume. 72 (3), 403-8.
 
4.Clarke, C.L., Ryan, C.G. and Martin, D.J., 2011. Pain neurophysiology education for the management of individuals with chronic low back pain: A systematic review and meta-analysis. Manual therapy, 16(6), pp.544-549.<br>5. Goldberg JS. (2008). Revisiting the Cartesian model of pain. Medical Hypotheses. 70 (5), 1029–1033.<br>6. Keller T and Krames ES. (2009). “On the Shoulders of Giants”: A History of the Understandings of Pain, Leading to the Understandings of Neuromodulation. Neuromodulation. 12 (2), 77-84.<br>7. Kooijmana CM, Dijkstraa PU, Geertzena JHB, Elzingad A, van der Schansa CP . (2000). Phantom pain and phantom sensations in upper limb amputees: an epidemiological study. Pain. 87 (1), 33–41.<br>8. Linton SJ. (2005). Models of pain perception. Understanding Pain for Better Clinical Practice: A Psychological Perspective. Elsevier . 9-18.<br>9. Louw A, Louw Q &amp; Crous LC. (2009). Preoperative education for lumbar surgery for radiculopathy. South African Journal of Physiotherapy, 65(2), 3-8.
 
10.Louw, A., Diener, I., Butler, D.S. and Puentedura, E.J., 2011. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of physical medicine and rehabilitation, 92(12), pp.2041-2056.<br>9. Louw A. (2014). Therapeutic Neuroscience Education: Teaching People About Pain. Available: http://www.instituteforchronicpain.org/treating-common-pain/what-is-pain-management/therapeutic-neuroscience-education. Last accessed 6th Janurary 2016.
 
10. Louw, A. and Puentedura, E.J., 2014. Therapeutic Neuroscience Education, Pain, Physiotherapy and the Pain Neuromatrix. International Journal of Health ScieLouw, A., Diener, I., Landers, M.R. and Puentedura, E.J., 2014. Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up. Spine, 39(18), pp.1449-1457.nces, 2(3), pp.33-45.
 
11. Melzack R, Wall PD &amp; Ty TC. (1982). Acute pain in an emergency clinic: latency of onset and descriptor patterns related to different injuries..Pain. 14 (1), 33-43.
 
12.Moseley, G.L., 2003. Joining forces–combining cognition-targeted motor control training with group or individual pain physiology education: a successful treatment for chronic low back pain. Journal of Manual &amp; Manipulative Therapy, 11(2), pp.88-94.
 
13.&nbsp;Moseley, G.L., 2004. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. European Journal of Pain, 8(1), pp.39-45.
 
14.Moseley, G.L., 2005. Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI evaluation of a single patient with chronic low back pain. Australian Journal of Physiotherapy, 51(1), pp.49-52.
 
15.Moseley, G.L. and Butler, D.S., 2015. Fifteen years of explaining pain: the past, present, and future. The Journal of Pain, 16(9), pp.807-813.<br>16. Jordan KP, Kadam UT, Hayward R, Porcheret M, Young C, Croft P. (2010). Annual consultation prevalence of regional musculoskeletal problems in primary care: an observational study. BMC Musculoskeletal disorders. 11 (144).<br>17. Balagué F, Mannion AF, Pellisé F, Cedraschi C. (2012). Non-specific low back pain. The Lancet. 4 (379), 482-91.<br>18. Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, York J, Das A, McAuley JH. (2008). Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 337 (a171).<br>19. National Institute for Health and Clinical Excellence (2015) Back pain - low (without radiculopathy). Clinical Knowledge Summary. London: NICE.<br> &nbsp; <br> *Summary: <br> *Concise summary or key points of the page. <br> *Resources and useful links: #Podcasts Chews health podcast SESSION 4 – KNOW PAIN: METAPHORIC EXPRESSION WITH MIKE STEWART – [http://chewshealth.co.uk/tpmpsession4/ PART 1], [http://chewshealth.co.uk/tpmpsession5/ PART 2] Know Pain course: A Practical guide for Therapeutic&nbsp;Neuroscience Education, course provider [http://physiouk.s3.amazonaws.com/Mike%20Stewart_Know%20Pain_Interview.mp3?inf_contact_key=f652f9d7e9bb1e1e7769a05d4cce3545ada22cb05afed3dc0bbf3a3f95e585cd discussion]&nbsp; #Youtube videos Lorimer Moseley Pain - How to Explain Pain to Patients youtube [https://www.youtube.com/watch?v=jIsF8CXouk8 video] #Books #Research #Website #Other <u></u><sub></sub><sup></sup><strike></strike>Membership required. Link: [http://www.csp.org.uk/icsp/topics/neuroscience-based-pain-education-resounding-success-or-damp-squib www.csp.org.uk/icsp/topics/neuroscience-based-pain-education-resounding-success-or-damp-squib] Know Pain course: A Practical guide for Therapeutic Neuroscience Education, course provider [http://www.physiouk.co.uk/course_pdfs/MikeS_Know_Pain_Transcript.pdf?inf_contact_key=ce65762746464ffc93c7afb89146987b5938f00a5ee899cc899e1bef4f1da23c discussion (transcription)] Explain Pain – [http://www.paintoolkit.org/downloads/epptkd.pdf Patient Leaflet]
 
<br>
 
[http://www.paintoolkit.org/downloads/epptkd.pdf]Book: Why Do I Hurt?&nbsp;Adriaan Louw (Available online)<br> *Conclusion of entire page. <br> *Resources <br> *References:

Latest revision as of 16:11, 18 November 2023

Original Editor - David Greaves, Lynette Fox, and Katie White as part of the Nottingham University Spinal Rehabilitation Project

Top Contributors - David Greaves, Lynette Fox, Becky Mead, Katie White, Kim Jackson, Maram Salem, Lucinda hampton, Uchechukwu Chukwuemeka, Vanessa Rhule, Rachael Lowe, Lauren Lopez, Rishika Babburu and Evan Thomas  

Introduction[edit | edit source]

PNE.webp

Chronic pain is defined as pain that lasts more than three months. It is a very common and prevalent problem that affects most age groups worldwide. Chronic pain is a multifactorial disorder that is influenced by biology, psychology, environmental, and social factors.[1] Pain Neuroscience Education (PNE) is a strategy that aims to teach patients to reshape their mindset and perception of pain despite these factors. It provides patients a better understanding of their condition and motivates them to become active participants in their treatment programs.

Based on a large number of high-quality studies, it has been shown that teaching people with chronic pain more about the neuroscience of their pain produces immediate and long-term changes. PNE has been shown to have positive effects in reducing pain, disability, and psychosocial problems, improving patient's knowledge of pain mechanisms, facilitating movement and decreasing healthcare consumption.[2]

Pain Neuroscience Education (PNE)[edit | edit source]

With respect to PNE, chronic pain is not viewed as a result of unhealthy or dysfunctional tissues. Rather, it is due to brain plasticity leading to hyper-excitability of the central nervous system, known as central sensitization.[3] The ultimate goal for Pain Neuroscience Education (PNE) is to increase pain tolerance with movement (e.g., be able to perform exercise with mild discomfort), reduce any fear associated with movement, and reduce central nervous system hypersensitivity. In practice, this often includes the use of educational pain analogies, re-education of patient misconceptions regarding disease pathogenesis, and guidance about lifestyle and movements modifications that can be introduced.

There are two clinical indications for initiating Pain Neuroscience Education (PNE)[4]:

  • the clinical picture is dominated by central sensitization
  • illness coping mechanisms or poor illness perception is present
Effects of central sensitization

Central sensitization is when there is amplification of pain in the central nervous system. It can result in hypersensitivity to stimuli, responsiveness to non-noxious stimuli, and increased pain response evoked by stimuli outside the area of injury, an expanded receptive field. [5]This can be assessed during the subjective and objective portion of a patient's evaluation. A physical therapist can determine what a patient's perception of their own pain is and how they cope with their pain.

Pain behaviors caused by central sensitization

PNE aims to reconceptualize pain to patients with these four main points:

  • Pain does not provide a measure of the state of the tissues
  • Pain is modulated by many factors from somatic, psychological, and social domains
  • The relationship between pain and the state of tissues becomes less predictable as pain persists
  • Pain can be conceptualized as the conscious correlate of the implicit perception that tissue is in danger[6]

Application of PNE[edit | edit source]

The application of PNE is most useful as part of a combination therapy for chronic pain that includes physiotherapy intervention (including exercise therapy) and may or may not include pharmacological treatment. Its application is best applied by trained and skilled clinicians with experience in managing patients with chronic pain conditions. Overall, PNE serves as a method of reconceptualizing a patient's perception of their pain experience, providing an avenue for reducing pain, disability and improving quality of life[6]. PNE puts the complex process of describing the nerves and brain into a format that is easy to understand for everyone regardless of age, educational level, or ethnic group.[7]

[8]

Methods of PNE delivery vary but can typically involve around 4 hours of teaching that is provided to a group or individually, either in single or multiple sessions.[9]PNE consists of educational sessions for patients describing in detail the neurobiology and neurophysiology of pain and pain processing by the nervous system.[7] It is implemented prior to administering physical therapy interventions with a verbal explanation. This is subsequently reinforced throughout the course of treatment to ensure proper carryover of reconceptualization of pain during and after discharge from physical therapy.

During the first educational session, the clinician should explain central sensitization along with the use any of the following: pictures, booklets, pamphlets, metaphors, drawings, question/answer assignments, and neurophysiology pain questionnaires. Topics addressed include acute pain vs. chronic pain, how it evolves from acute pain to chronic pain, interpretation of stimuli to the nervous system, and external factors that may impact pain (such as anxiety, stress, depression, pain perceptions, and behavior). Patients are encouraged to read the handouts or brochures handed to them from the clinician at home.[4]

During subsequent sessions, the patient is encouraged to ask questions and receive clarification for any questions they may have about the neurophysiology of their pain. The clinician can address psychosocial aspects of a patient's pain during any visit. Some examples of clinically indicated advice that can be provided include advising the patient to stop worrying about their pain, reduce stress, implement relaxation techniques, and become more physically active. The treatment rationale should be provided throughout the patient's plan of care. Continually reinforcing and educating the patient regarding their pain physiology is recommended. The overarching goal is to motivate and encourage the patient to complete their treatment program in order to achieve their functional goals. [4]

Figure 4. illustrates the content of PNE education sessions with patients[7]

Figure showing the content of PNE education sessions

An example of a metaphor or story that can be used with patients is provided here: http://www.instituteforchronicpain.org/treating-common-pain/what-is-pain-management/therapeutic-neuroscience-education.

PNE for Chronic Musculoskeletal Conditions[10][edit | edit source]

Chronic MSK conditions with positive PNE results

These conditions are often characterised by brain plasticity that leads to hyperexcitability of the central nervous system (central sensitisation). Figure 5 highlights chronic musculoskeletal conditions that benefit from PNE, including osteoarthritis, fibromyalgia, pelvic pain, whiplash, lateral epicondylitis, and low back pain.[11][12]

Recent studies suggest that PNE in conjunction with either therapeutic exercise or manual therapy yielded significant reduction in pain ratings.[13]


References[edit | edit source]

  1. ↑ Mills SEE, Nicolson KP, Smith BH. Chronic pain: a review of its epidemiology and associated factors in population-based studies. Br J Anaesth. 2019 Aug;123(2):e273-e283.
  2. ↑ Zimney KJ, Louw A, Cox T, Puentedura EJ, Diener I. Pain neuroscience education: Which pain neuroscience education metaphor worked best?. South African Journal of Physiotherapy. 2019 Jan 1;75(1):1-7. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6739553/(accessed 19.4.2022)
  3. ↑ Nijs J, Girbés EL, Lundberg M, Malfliet A, Sterling M. Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories. Manual therapy. 2015; 20 (1): 216-220.
  4. ↑ 4.0 4.1 4.2 Nijs, J., Paul van Wilgen, C., Van Oosterwijck, J., van Ittersum, M., Meeus, M.,How to explain central sensitization to patients with ‘unexplained’ chronic musculoskeletal pain: Practice guidelines, Manual Therapy, 2011, 16:5, 413-418
  5. ↑ Central Sensitisation
  6. ↑ 6.0 6.1 Moseley GL. Reconceptualising pain according to modern pain science. Physical therapy reviews. 2007 Sep 1;12(3):169-78.
  7. ↑ 7.0 7.1 7.2 Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of physical medicine and rehabilitation. 2011; 92(12):2041-2056.
  8. ↑ Pain Neuroscience Education PAINWeek Available:https://www.youtube.com/watch?v=6RGP_usIbBU (accessed 19.4.2022)
  9. ↑ Clarke CL, Ryan CG, Martin DJ. Pain neurophysiology education for the management of individuals with chronic low back pain: A systematic review and meta-analysis. Manual therapy. 2011; 16(6):544-549.
  10. ↑ Moseley GL, Butler DS. Fifteen years of explaining pain: the past, present, and future. The Journal of Pain. 2015;16(9):807-813.
  11. ↑ Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up. Spine. 2014; 39(18):1449-1457.
  12. ↑ Zimney K, Louw A, Puentedura EJ. Use of Therapeutic Neuroscience Education to address psychosocial factors associated with acute low back pain: a case report. Physiotherapy theory and practice. 2014; 30(3):202-209.
  13. ↑ Louw, A., Zimney, K., Puentedura, E., Diener, I., The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature, Physiotherapy Theory and Practice, 2016, 32:5, 332-355.
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