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== Introduction  ==
== Introduction  ==
[[File:Pain knowing-neurons.jpg|right|frameless]]
[[File:PNE.webp|right|frameless|234x234px]]
Pain neuroscience education (PNE) is a strategy that teaches patients to rethink the way they view [[Pain Behaviours|pain]].  Pain neuroscience education utilises various stories and metaphors to help patients reconceptualise their pain experience. Clinicians may often underestimate the ability of a patient to understand the complexities of pain, as they are generally invested in learning about how to treat their pain<ref name=":0">Project Physio PNE Available:https://www.project-physio.com/pain-neuroscience-education (accessed 19.4.2022)</ref>.  
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.


PNE aims to increase pain thresholds during exercise, decrease fear related to movement and decreased brain activity in brain regions associated with pain. 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.  
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>


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.<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>
== Pain Neuroscience Education (PNE) ==


== Pain Neuroscience Education ==
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 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">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> 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|back school]] and biomechanical models.<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>
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>:


[[Chronic Pain and the Brain|Chronic pain]] in PNE is seen as not being caused not by unhealthy or dysfunctional tissues but [[Neuroplasticity|brain plasticity]] leading to hyper-excitability of the central nervous system, known as central sensitisation.<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> [[Image:Effects_of_central_sensatisation.png|300x200px|alt=|thumb|Effects of central sensatisation]][[Central Sensitisation|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:
* the clinical picture is dominated by central sensitization
# Hypersensitivity to stimuli.
* illness coping mechanisms or poor illness perception is present
# Responsiveness to non-noxious stimuli.
[[Image:Effects_of_central_sensatisation.png|313x313px|alt=|thumb|Effects of central sensitization]]
# Increased pain response evoked by stimuli outside the area of injury, an expanded receptive field.


== Application ==
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:
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 reconceptualising 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" />.
* Pain does not provide a measure of the state of the tissues
 
* Pain is modulated by many factors from somatic, psychological, and social domains
* eg 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.<ref name=":1" />  
* 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>


This is a good 4 minute video explaining PNE
== Application of PNE  ==
{{#ev:youtube|?v=6RGP_usIbBU|width}}<ref>Pain Neuroscience Education PAINWeek
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>
  Available:https://www.youtube.com/watch?v=6RGP_usIbBU (accessed 19.4.2022)</ref>
== What is Pain ==
[[File:Upload_version_of_systemic_effects.jpg|alt=|thumb|426x426px|Pain behaviours caused by central sensitisation]]Mosely (2007) describes pain in a reconceptualised manner:
* 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 conceptualised as the conscious correlate of the implicit perception that tissue is in danger<ref name=":0" />


&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;
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.
== What Does PNE Involve?  ==


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.<ref name=":10" />  
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" />


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'''
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" />  


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" />  
Figure 4. illustrates the content of PNE education sessions with patients<ref name=":10" />  


Figure 6. showing the content of PNE education sessions with patients<ref name=":10" /><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]]


[[Image:Methods of PNE.jpg|center|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. 


== How is PNE Used in Clinical Practice? ==
=== 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> ===
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.<ref name=":6" /> 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.<ref name=":6" /> 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.
[[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>


== Indicators For the Use of PNE  ==
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>


=== 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 ]]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.
*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&nbsp;
*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>


== References ==
== References ==
<references />  
<references />  


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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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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