Pain Neuroscience Education (PNE): Difference between revisions

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# Increased pain response evoked by stimuli outside the area of injury, an expanded receptive field.
# Increased pain response evoked by stimuli outside the area of injury, an expanded receptive field.


<br>Pre-existing factors (genetics) that may predispose an individual to have altered central nervous system functioning following injury<br>Factors (environmental) that may cause altered central nervous system functioning once injury has occurred. i.e. (anxiety, stress, depression, fear-avoidance and poor sleep)<br>[[Image:Upload_version_of_systemic_effects.jpg|Figure 4:Systemic effects of central sensitisation (McAllister, 2012)|500x500px]]
<br>Pre-existing factors (genetics) that may predispose an individual to have altered central nervous system functioning following injury<br>Factors (environmental) that may cause altered central nervous system functioning once injury has occurred. i.e. (anxiety, stress, depression, fear-avoidance and poor sleep)<br>


Figure 5: Pain behaviours caused by central sensitisation
Figure 5: Pain behaviours caused by central sensitisation


== History of Pain Models and Development of PNE  ==
=== Pain-Neuroscience Education Model ===
[[File:Upload_version_of_systemic_effects.jpg|alt=|thumb|500x500px|Pain behaviours caused by central sensitisation]]
In the last century Descartes biomedical model has been replaced by the [http://www.physio-pedia.com/Biopsychosocial_Model biopsychosocial model] of [http://www.physio-pedia.com/Chronic_Pain chronic pain]<ref name=":12">Goldberg JS. Revisiting the Cartesian model of pain. Medical Hypotheses. 2008;70 (5):1029–1033.</ref>, in which pain is classified as being due to increased sensitivity of the nervous system rather than further injury.<ref name=":11">Linton SJ. Models of pain perception. Understanding Pain for Better Clinical Practice: A Psychological Perspective. Elsevier, 2005. p9-18.</ref> 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<ref name=":5">Louw A. Therapeutic Neuroscience Education: Teaching People About Pain. 2014. Available from: http://www.instituteforchronicpain.org/treating-common-pain/what-is-pain-management/therapeutic-neuroscience-education. (accessed 6 Janurary 2016). </ref>; i.e. a much lower degree of movement provocation causes pain.


The biomedical model is most commonly used by physiotherapists and other medical health professionals for the management of pain.<ref name=":11">Linton SJ. Models of pain perception. Understanding Pain for Better Clinical Practice: A Psychological Perspective. Elsevier, 2005. p9-18.</ref><ref name=":5">Louw A. Therapeutic Neuroscience Education: Teaching People About Pain. 2014. Available from: http://www.instituteforchronicpain.org/treating-common-pain/what-is-pain-management/therapeutic-neuroscience-education. (accessed 6 Janurary 2016). </ref> The model follows that pain and injury interrelated, thus an increase in pain means further tissue damage have occurred and vice-versa.<ref name=":5" /> This model, called the Cartesian model, is over 450 years old, and many argue inaccurate and significantly outdated.<ref name=":5" />
People in pain are interested in pain and more specifically the mechanisms of pain.<ref>Louw A, Louw Q, Crous LC. Preoperative education for lumbar surgery for radiculopathy. South African Journal of Physiotherapy. 2009; 65(2):3-8.</ref> 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.&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;
 
The Cartesian ‘mid-body’ was first proposed in the early 16th Century by the French Philosopher, Mathematician and Scientist Rene Descartes, in an attempt to show that humans were a mechanical body controlled by a rational soul.<ref name=":11" /> 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
 
===  Why is the Model Considered Outdated?  ===
 
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.<ref name=":11" /> Clinicians frequently use the biological model to explain patient’s pain, describing pain as being due to either disc, joint or abnormal movement pattern.<ref name=":5" /> 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.<ref name=":5" />
 
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.<ref name=":11" /> 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<ref name=":12">Goldberg JS. Revisiting the Cartesian model of pain. Medical Hypotheses. 2008;70 (5):1029–1033.</ref>
*Similar injuries in different patients caused substantially different pain responses<ref name=":12" />
*An incision to the skin twice as deep as that of another, does not hurt twice as much<ref name=":12" />
*Why 40% of people with horrific injuries felt either no or a low intensity of pain<ref>Melzack R, Wall PD, Ty TC. Acute pain in an emergency clinic: latency of onset and descriptor patterns related to different injuries.. Pain. 1982; 14 (1):33-43. </ref>
*Why up to 70% of people's do not report pain or associated symptoms consistent with their X-ray/ MRI finding <ref>Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation.. Journal of Bone and Joint Surgery American 1990; 72 (3): 403-8.</ref><ref>Bhattacharyya T, Gale D, Dewire P, Totterman S, Gale ME, McLaughlin S, et al. The clinical importance of meniscal tears demonstrated by magnetic resonance imaging in osteoarthritis of the knee. Journal of Bone and Joint Surgery American. 2003; 85-A (1):4-9.
</ref>
*Why 51% of amputees reported phantom pain and 76% phantom sensations including: cold, electric sensations and movement in the phantom limb.<ref>Kooijmana CM, Dijkstraa PU, Geertzena JHB, Elzingad A, van der Schansa CP. Phantom pain and phantom sensations in upper limb amputees: an epidemiological study. Pain. 2000; 87 (1):33–41.</ref>
 
Furthermore in Beecher’s<ref>Beecher HK. The Relationship to the Significance of Wound to Pain Experienced. Journal of the American Medical Association. 1956;161 (17):1609-13.</ref> 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 dependent. This example therefore proposes that the patient's beliefs emotions and past experiences of pain can alter the brains interpretation of the pain. However the validity of study findings must be questioned, as investigations were conducted 60 years ago, thus may be significantly outdated. Furthermore the study did not consider the effect of shock or adrenaline, which has been proposed to influence immediate pain responses.
 
===  The Pain-Neuroscience Education Model  ===
 
In the last century Descartes biomedical model has been replaced by the [http://www.physio-pedia.com/Biopsychosocial_Model biopsychosocial model] of [http://www.physio-pedia.com/Chronic_Pain chronic pain]<ref name=":12" />, in which pain is classified as being due to increased sensitivity of the nervous system rather than further injury.<ref name=":11" /> 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<ref name=":5" />; i.e. a much lower degree of movement provocation causes pain.
 
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.<ref>Louw A, Louw Q, Crous LC. Preoperative education for lumbar surgery for radiculopathy. South African Journal of Physiotherapy. 2009; 65(2):3-8.</ref>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.&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;&nbsp;


==== Video of Alarm Systems  ====
==== Video of Alarm Systems  ====
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== Indicators For the Use of PNE  ==
== Indicators For the Use of PNE  ==


=== Chronic Musculoskeletal Conditions<ref name=":13" /> ===
=== 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|right]]These conditions are often characterised by brain plasticity that leads to hyperexcitability of the central nervous system (central sensitisation).&nbsp;  
[[Image:Chronic MSK conditions.jpg|alt=|thumb|Chronic MSK&nbsp;conditions with positive PNE results ]]These conditions are often characterised by brain plasticity that leads to hyperexcitability of the central nervous system (central sensitisation).&nbsp;  


*PNE is recommended in<br>central sensitisation conditions like these,<br>as the patient may present with maladaptive<br>cognitions, behaviour, or coping<br>strategies in response to pain.  
*PNE is recommended in<br>central sensitisation conditions like these,<br>as the patient may present with maladaptive<br>cognitions, behaviour, or coping<br>strategies in response to pain.  
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*Evidence showing benefits for pre op MSK patients.<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>
*Evidence showing benefits for pre op MSK patients.<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>


<br>Figure 7. (right): showing chronic MSK&nbsp;conditions with positive PNE results from current evidence.<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>
== References ==
 
== The Benefits and Drawbacks of PNE  ==
 
==== Table 1:showing the benefits and drawbacks of PNE<ref name=":6" /><ref>Moseley GL. 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. 2003; 11(2):88-94. .
</ref><ref>Moseley GL. 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. 2004; 8(1):39-45. .
</ref>  ====
{| class="wikitable" width="100%" cellspacing="1" cellpadding="1" border="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
|}
 
== Brain Activity Clinical Imaging of PNE Effect  ==
 
=== Types of Brain Activity Imaging ===
There are various types of brain imaging to show brain activity in pain states, some scans of which are pictured below:
 
[[Image:PET, MRS and fMRI.png]]
 
Figures 8 - 10: left to right are Positron emission tomography (PET), magnetic resonance spectroscopy (MRS) and&nbsp;functional magnetic resonance imaging (fMRI) of pain.<ref>Sharma NK, Brooks WM, Popescu AE, VanDillen L, George SZ, McCarson KE, et al. Neurochemical analysis of primary motor cortex in chronic low back pain. Brain sciences. 2012; 2(3):319-331.</ref><ref name=":8">Cole LJ, Farrell MJ, Duff EP, Barber JB, Egan GF, Gibson SJ. Pain sensitivity and fMRI pain-related brain activity in Alzheimer's disease. Brain. 2006; 129(11):2957-2965.</ref><ref>Casey KL, Morrow TJ, Lorenz J, Minoshima S. Temporal and spatial dynamics of human forebrain activity during heat pain: analysis by positron emission tomography. Journal of Neurophysiology. 2001;85(2):951-959.</ref>
 
===Effects of PNE Imaged===
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. The effects of decreased pain related brain activity are measurable via brain imaging as demonstrated in the example below:
 
A high-level dancer who was scheduled for back surgery in two days due to&nbsp;experiencing significant back pain for almost two years, was scanned using fMRI. Areas of brain activity related to pain were demarcated in red.
 
Figure 11:&nbsp;row 1 -&nbsp;patient relaxing. Note no red areas. <br>[[Image:FMRI row 1.png]]<br>
 
Figure 12: row 2 -&nbsp;patient was asked her to move her painful back while in the scanner. These images demonstrated brain activity related to pain whereby larger areas of red signifies more pain related activity, hence more pain.
 
[[Image:FMRI row 2.png]]<br>
 
Figure 13: row 3 - after initial scans the patient was taken out of the scanner and provided with a teaching session about pain for 20-25 minutes. Following this, the scan of the patient was immediately repeated doing the same painful task as performed in Row 2. Note this time however, there was significantly less activity (fewer red areas) despite performing the same movement.<ref name=":6" /><br>
 
[[Image:FMRI row 3.png]]<br>
 
There is an obvious link with patient catastrophising thoughts and pain related brain activity, shown by the immediate reduction in brain activity following PNE provision in the above example. Furthermore, there is a link in attention to pain that when negatively perceived, impacts on the experience of pain being greater. One study<ref name=":8" /> demonstrated that pain related brain activity was greater in patients 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?
 
== Critical Appraisal of the Evidence  ==
 
=== Paper 1:The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain<ref name=":10" /> ===
A recent systematic review investigating the benefits of pain neuroscience education (PNE), discovered that PNE significantly decreased pain, pain catastrophisation and perceived disability compared to the control group (ongoing medical care), in both the short and long-term. Although the review searched all major databases, only 8 studies were included in the review, with all included studies having either good, very good or excellent methodological quality. 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 no consensus to the number of required sessions. 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 the treatment of LBP.<br>
 
[[Image:Becky mead table of evidence.png]]<br>
 
=== Paper 2: Preoperative Pain Neuroscience Education for Lumbar Radiculopathy<ref name=":6" /> ===
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 PNE for lumbar radiculopathy.
 
[[Image:Louw et al., 2014 table 1.jpg|center]]
 
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. Sample size powered. 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, or a patient with non-specific low back pain must be applied with caution despite promising outcomes due to the specificity of the results to surgery for radiculopathy.
 
=== Paper 3: Pain neurophysiology education for the management of individuals with chronic low back pain: A systematic review and meta-analysis' ===
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<ref name=":4" />, investigated the impact of PNE, specifically on that management of patients with chronic low back pain.[[Image:SR on PNE 1.jpg|center]]<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 et al.<ref name=":10" /> 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.
 
=== Paper 4: Use of therapeutic neuroscience education to address psychosocial factors associated with acute low back pain: a case report<ref name=":7" /> ===
<br>Despite some research being done for chronic pain, scant evidence exists in PNE as a treatment in acute pain as a method of preventing chronic pain. This case study attempts to address this issue to guide the way for further research.[[Image:PNE data extraction table Lynette. pic2.png|center]]
 
Although case reports aren’t generalisable or robust they do provide a unique opportunity to present pilot evidence to inform the direction of RCT’s, reviews and guidelines. As a case report the limitations are that use of controls are not a necessity, thus the outcomes for this patient may purely be spontaneous recovery, furthermore other Rx provided in addition to PNE may be credited.
 
== Clinical Bottom Line  ==
 
Due to the limited numbers of studies, study specificity and relatively poor level of methodological quality; currently it is difficult to draw solid conclusions to the specific clinical benefits of PNE for reducing LBP, perceived disability and function.
 
== Resources  ==
# KNOW PAIN: METAPHORIC EXPRESSION WITH MIKE STEWART –[http://chewshealth.co.uk/tpmpsession4/ PART 1], [http://chewshealth.co.uk/tpmpsession5/ PART 2]
# [https://www.youtube.com/watch?v=jIsF8CXouk8 How to Explain Pain to Patients]
# [http://www.paintoolkit.org/downloads/epptkd.pdf A Practical guide for Therapeutic Neuroscience Education]
 
== References ==
<references />  
<references />  


Revision as of 02:55, 19 April 2022

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  
Page Owner - Ina Diener as part of the One Page Project

Introduction[edit | edit source]

Pain knowing-neurons.jpg

Pain neuroscience education (PNE) is a strategy that teaches patients to rethink the way they view pain. Pain neuroscience education utilises various stories and metaphors to help patients reconceptualise their pain experience.

Based on a large number of high-quality studies, it has been shown that teaching people with pain more about the neuroscience of their pain produces some impressive 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.[1]

Pain Neuroscience Education[edit | edit source]

PNE consists of educational sessions for patients describing in detail the neurobiology and neurophysiology of pain and pain processing by the nervous system.[2]
This educational approach has been used by physiotherapists therapeutically since 2002 in various countries (eg UK, US, Australia) and differs considerably from traditional education strategies such as back school and biomechanical models.[3] Chronic pain in PNE is seen as not being caused not by unhealthy or dysfunctional tissues but brain plasticity leading to hyper-excitability of the central nervous system, known as central sensitisation.[4] Therefore, a deeper level reasoning and treatments beyond a medical model is required.

Initially, PNE changes a patient’s perception of pain.

  • 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.[4]

Central Sensitisation[edit | edit source]

Effects of central sensatisation

Central sensitisation is defined as an increased responsiveness of nociceptors in the central nervous system to either normal or sub-threshold afferent input resulting in:

  1. Hypersensitivity to stimuli.
  2. Responsiveness to non-noxious stimuli.
  3. Increased pain response evoked by stimuli outside the area of injury, an expanded receptive field.


Pre-existing factors (genetics) that may predispose an individual to have altered central nervous system functioning following injury
Factors (environmental) that may cause altered central nervous system functioning once injury has occurred. i.e. (anxiety, stress, depression, fear-avoidance and poor sleep)

Figure 5: Pain behaviours caused by central sensitisation

Pain-Neuroscience Education Model[edit | edit source]

Pain behaviours caused by central sensitisation

In the last century Descartes biomedical model has been replaced by the biopsychosocial model of chronic pain[5], in which pain is classified as being due to increased sensitivity of the nervous system rather than further injury.[6] 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[7]; i.e. a much lower degree of movement provocation causes pain.

People in pain are interested in pain and more specifically the mechanisms of pain.[8] 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.                                                            

Video of Alarm Systems[edit | edit source]

What Does PNE Involve?[edit | edit source]

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.[2]

This is made possible by using simplified scientific language used with additional methods of presenting information that may include the use of:
• Simple pictures
• Examples
• Booklets
• Metaphors
• Drawings
• Workbook with reading/question-answer assignments
• Neurophysiology Pain Questionnaires

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.[3]

Figure 6. showing the content of PNE education sessions with patients[2]

Figure showing the content of PNE education sessions

How is PNE Used in Clinical Practice?[edit | edit source]

A metaphor/story that can be found here: (http://www.instituteforchronicpain.org/treating-common-pain/what-is-pain-management/therapeutic-neuroscience-education) is used by Louw et al.[9] in clinical practice to teach patients about complex pain physiology including extra-sensitive nerves, inflammation, injury and 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.[9] 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.

Video Interview of Low Back Pain From a Patient's Point of View[edit | edit source]

Indicators For the Use of PNE[edit | edit source]

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). 

  • PNE is recommended in
    central sensitisation conditions like these,
    as the patient may present with maladaptive
    cognitions, behaviour, or coping
    strategies in response to pain.
  • Typically they acquire a protective (movement-related) pain memory, which causes a barrier to adhere to therapeutic treatment such as exercise, decreasing the likelihood of a good outcome.
  • Therefore these maladaptive behaviours, central sensitisation and previous failed treatments are all indicators for PNE 
  • Evidence showing benefits for pre op MSK patients.[9][11]

References[edit | edit source]

  1. ↑ 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)
  2. ↑ 2.0 2.1 2.2 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.
  3. ↑ 3.0 3.1 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.
  4. ↑ 4.0 4.1 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.
  5. ↑ Goldberg JS. Revisiting the Cartesian model of pain. Medical Hypotheses. 2008;70 (5):1029–1033.
  6. ↑ Linton SJ. Models of pain perception. Understanding Pain for Better Clinical Practice: A Psychological Perspective. Elsevier, 2005. p9-18.
  7. ↑ Louw A. Therapeutic Neuroscience Education: Teaching People About Pain. 2014. Available from: http://www.instituteforchronicpain.org/treating-common-pain/what-is-pain-management/therapeutic-neuroscience-education. (accessed 6 Janurary 2016). 
  8. ↑ Louw A, Louw Q, Crous LC. Preoperative education for lumbar surgery for radiculopathy. South African Journal of Physiotherapy. 2009; 65(2):3-8.
  9. ↑ 9.0 9.1 9.2 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.
  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. ↑ 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.

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.

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