View source for Pain Neuroscience Education (PNE) for Low back pain

== Clinical application of PNE ==
One aspect of PNE within the literature with little controversy is that PNE produces the most favourable outcomes when used in conjunction with more 'traditional' physiotherapy treatments. Utilising the current literature, in particular a study from Louw et al. (2016)<ref>Louw, A., Zimney, K., O’Hotto, C. and Hilton, S. (2016). The clinical application of teaching people about pain. Physiotherapy Theory and Practice, 32(5), pp.385–395. doi:10.1080/09593985.2016.1194652.‌</ref>, we have outlined a strategy which clinicians can utilise to incorporate PNE into their practice. 

=== First session ===
Within the first session, a comprehensive assessment of the patient will be completed. This is like a 'traditional physiotherapy assessment' as it gathers both subjective and objective information which the clinician can utilise to inform their diagnosis and treatment. We propose the first session should be split into 4 sections which should total to around 1 hour:
[[File:PNE- Initial session.png|alt=|center|frameless|750x750px]]
# [[File:Clinician_prompts_for_conversation.png|alt=|right|frameless]]'''Conversation/interview''' ''(~25-30mins)''':''''' Initially clinicians should have a conversation with the patient where they predominantly listen to the patient, gathering information about their experiences, suffering and beliefs. This part should not be rushed, and adequate time is needed for the patient to tell their own story. Within this time the clinician can take note of any issues/beliefs which the patient mentions which may need to be addressed in later PNE sessions.
# '''Physical examination''' ''(~10 mins)''''':''' It is important that significant pathologies are ruled out to ensure that there is no underlying sinister pathology. Physical examination will also give us objective markers that we can utilise to track the progress of individuals to see if treatment is effective. The results from this examination should be conveyed to the patient, with emphasis on the use of clinician language to avoid terms like “wear and tear” which have negative connotations.
# '''Introduction to PNE''' (~10-15mins)''':''' Depending on the time availability of the clinician following a thorough assessment, PNE can then be briefly introduced to the patient. A good way to start the conversation is asking “Has anyone explained to you why you are still experiencing pain?”.   If the patient is interested in learning more this is when a brief metaphor can be used to start to explain the hyper sensitive nervous system which is contributing to their pain.   A common metaphor used is an oversensitive alarm clock (described below), however there is a number of metaphors used within pain education and research has found that no individual story or metaphor is superior to another <ref>Louw, A., Puentedura, E.J., Diener, I., Zimney, K.J. and Cox, T. (2019). Pain neuroscience education: Which pain neuroscience education metaphor worked best? ''South African Journal of Physiotherapy'', 75(1). doi:10.4102/sajp.v75i1.1329.</ref>. 'Tame the beast' by Lorimer Moseley is another popular metaphor which can be utilised by patients, one benefit to this metaphor is that it has a patient centred video which clinicians can signpost a patient to if they are short of time in the initial session.{{#ev:youtube|ikUzvSph7Z4}}<ref>Lorimer Moseley. Tame The Beast — It’s time to rethink persistent pain. YouTube. Available at: https://www.youtube.com/watch?v=ikUzvSph7Z4&t=204s [Accessed 19 May 2022].‌ </ref>
'''4. Exercise prescription''' (~10-15mins)''':''' As PNE is most effective when used in conjunction with other therapies, simple exercises should be given to the patient to encourage movement. The patient should perform the exercise during the session and the clinician should discuss the patients perception of the exercise, challenging any inaccurate beliefs utilising the PNE metaphor.

Depending on the time available to the clinician this initial session may need to be split into two sessions, however the sessions should then be delivered within a short time frame of each other.  

===== The oversensitive alarm clock =====
[[File:Alarm clock metaphor.png|thumb|Normal response of nervous system]]
To begin with we must explain to patients the complexity of the nervous system; there are more than 400 individual nerves which all connect like roads, if they were all combined and laid out they would cover more than 45 miles (ref).We can then explain how a healthy nervous system works, introducing the metaphor of an alarm clock:

"When we step on a pin while barefoot we need to know about it so that we can remove the danger and take care of ourselves. The nervous system works like an alarm clock, sending a message to the brain producing pain so that we can take action such as removing the pin from our foot. The alarm will then calm down and is ready to warn you of any future danger such as stepping on another pin." Using illustrations will help to explain this metaphor. We can then apply this to the patients presenting problem.
[[File:Alarm clock metaphor- sensitive nervous system.png|thumb|Response of a sensitive nervous system]]
We can then explain to the patient that in approximately 1 in 4 people the alarm system does not calm down and stays extra sensitive: "Before you had the onset of pain the alarm clock had lots of space for activities before the alarm would be triggered but because it is very sensitive there is little room for activities before the alarm goes off. (That explains why your back hurts after standing up for 5 minutes.)" Again the use of an illustrations can help a patient to understand this. 

We can then round up the brief introduction by explaining that there is a lot of factors that are contributing to this hypersensitivity, which you can then discuss in later sessions. It is also important that you explain that there are strategies we can use to calm the alarm clock down to give the patient the reassurance that things will get better. "There are things that are making your alarm clock extra sensitive and also strategies we can use to help calm your alarm clock down. We can discuss these in your later sessions but the main thing is that we start to calm your alarm clock down to give you more room for activities."

==== 'Homework' ====
It is important that we encourage patients to take an active role in their own recovery. We should provide patients with the relevant tools to enable this and increase their self-efficacy. Giving patients a few simple tasks can help to promote this. These can include:

# '''Question Generation:''' Encourage the patient to write down any questions that they may have regarding pain and the PNE material covered in the session. This helps to remove doubts and increase their understanding of pain experiences.
# '''Encourage exercises:''' Exercise help to enhance movement and increase function. A focus on breathing and relaxation should be emphasised during the exercise with reference to PNE and relaxation of the hypersensitive nervous system.
# '''Aerobic exercise:''' Starting very small in an exercise of their own choice (walking, swimming, cycling, running etc.) patients should be encouraged to participate in aerobic exercise. The benefits should be explained to the patient in terms of the down regulation of the sensitised nervous system.
# '''Set goals:''' Patient should be encouraged to list 5 goals they wish to achieve prior to the next session. Asking the patient “If you could flip a switch and get rid of all your pain, what would you do again?”


Clinicians should use their own judgement when giving patient tasks to complete at home, some proactive patients will complete all tasks before the next session, while those with low self efficacy may be overwhelmed when given a large number of tasks. One way to combat this is to give patient 1-2 tasks at a time, a clinician should use their own judgement to determine the tasks to prescribe and what tasks can be introduced in later sessions.

==== Subsequent sessions ====
Subsequent session should be individualised to patients and their journey with PNE. The content of these sessions are dependent on what was covered in the previous session e.g. if  there was not time in the last session to discuss the importance of aerobic exercise or to teach the patients relaxed breathing techniques then this could be a priority for the next session. A useful structure for later PNE could be:

# '''Question and answer:''' Discuss any questions the patient had about the previous session. If patients do not have any questions the clinician could ask the patient about what they understood from the previous session, this can help identify any areas which patients were unsure of or had forgotten which can then be revisited.
# '''Progress PNE:''' New metaphors, pictures or information can be discussed with the patient. These should be relevant to the patients experience or findings. 
# '''Review goals:''' Break the patients goals down into SMART goals. This encourages pacing and graded exposure which can help to motivate patients throughout their journey. Each session the goals should be reviewed, and patient should be encouraged to progress to the next stage if appropriate.
# '''Traditional therapy:''' The clinician should use their own clinical judgement to determine if the patient would benefit from other treatments such as manual therapy. The exercises from previous session should be reviewed and new exercises prescribed to encourage increase function.