A recent paper (1) critiques the use of Pain Neuroscience Education*. The article is now used to promote the notion that Pain Neuroscience Education (PNE) has no clinical value. The paper noted, “People with persistent pain tend to express negative attitudes to PNE statements.” However, there are several problems and methodological flaws in the study.
An error the paper makes is it conflates negative attitudes with no benefit; people could have a negative attitude but still see a benefit. A separate error is that the lead author has been highly vocal about his negative feelings against using Pain Neuroscience Education for several years. So, it is no surprise that his experiment had the findings it had. The paper tested whether naive people (who may or may not have pain) agreed with or thought the statements of Pain Neuroscience Education are ‘true’. Not whether Pain Neuroscience Education has value and benefits.
Pain Neuroscience Education is not perfect
Now, Pain Neuroscience Education is far from perfect. One criticism I have had towards Pain Education is when it is misapplied without any sound clinical reasoning. It is misused when seen as another tool in the clinical toolbox. I have had this criticism for some time. Pain Education is falsely seen as a new clinical religion applied to all people with pain without adequately assessing if a considerable biological contributor influences the person’s pain.
As Mick Thacker said: “Pain is not a good indicator of tissue damage… Except when it is! The skill is knowing when!”
Clinically, I see severely ill people and people with pelvic fractures, femur fractures, hip fractures, collum chirurgicum fractures, and compression fractures, all in the acute state. I never try to explain their pain away or ignore their pain or teach them to ignore their pain. Injuries and trauma can highly influence pain.
Does this paper mean that Pain Education is without value? No, but misapplied Pain Education without any sound clinical reasoning is without value; lecturing patients about their pain is equally of no value.
Nonetheless, many people living with pain are sort of trapped in a biomedical maze without an exit. Believing there must be an actual biomedical cause for their back pain. If we use back pain as an example, research data clearly says that in 90% of people with back pain, there is no known pathological or anatomical cause for their pain (2, 3). Believing that you have an injury when with a high probability you don’t have an injury is also harmful. In this case, Pain Neuroscience Education could potentially help; Joletta Belton (below) and Trevor Barker are examples of this happening.
”If just one PT had told me that pain wasn’t in my tissues, that pain doesn’t equal damage, that it’s more complex than that, especially the longer we’re in it, it may have saved me years of suffering.” Joletta Belton
Now, is Pain Neuroscience Education an easy one-shot cure for people living with pain? Clearly not!
One severe setback to the applicability of Pain Neuroscience Education is the biomedical environment most people with pain live in. As mentioned before, many people living with pain firmly believe in a biomedical cause of their pain; trying to help them gain a less wrong perspective does not often increase satisfaction.
“Basically, if you tell anyone some of the statements we know about pain, they won’t believe it – because these beliefs are in the general public, promoted for decades from within the biomedical community, and biomedicine is the dominant discourse for those not involved in healthcare.” Dr. Bronnie L. Thompson, PhD
As noted by Chalmers et al., “Further, they are likely to encounter other healthcare professionals whose personal ideas about pain more closely resemble the patient’s original and outdated beliefs and who, by their interactions with the patient, may unwittingly obstruct recovery from persistent pain.” (4). An often missed and overlooked part in the therapeutic encounter and in using Pain Neuroscience Education is the skillset of the clinician. It takes a lot of listening, caring, and good interpersonal communication skills to be good at it. As it has been said, to be able to advise someone, they first need to accept you as someone they want to receive advice from.
This was confirmed by Bunzli et al.(5), who found that for people (living with pain) to change their outdated biomedical beliefs in favor of a biopsychosocial perspective, it required a robust therapeutic alliance with their therapist. Numerous papers show some benefits of Pain Neuroscience Education (6,7,8,9,10,11,12), but research indicates that the benefits may not be applicable in the acute state (13).
The central premise behind Pain Neuroscience Education is to help people living with pain understand more about what we currently know about pain to facilitate behavior and belief change. Thereby reducing the harmful effects of outdated pain beliefs. Research indicated that these beliefs are the most prominent influence in pain-associated disability (14) and are part of the psychosocial context.
The newly published 3rd Edition of Pain: A Textbook for health professionals by van Griensven and Strong (15) has an excellent primer on Pain education for patients written by pain advocate Joletta Belton and Joost Van Wijchen; they hit the nail on the head with this paragraph:
“To summarise, pain education should not be something clinicians do to or give to a passive patient. Education is co-constructive learning and a way of becoming more capable. In this way, pain education becomes a dynamic, collaborative, transformative process that fosters learning and change. Through conversation and learning from and with one another, patient and clinician come to a shared understanding of what is happening and decide—together— what to do about it (Low 2020). By bringing together the patient’s story and the clinician’s relevant training, expertise and knowledge of current research, a narrative about pain can be cocreated that is more accurate and therapeutic, and makes both biological and biographical sense” (15).
Thanks to Dr. Bronnie L. Thompson and Joost Van Wijchen for their feedback on this blog.
*Pain Education for Patients is referred to in research literature as Pain Education, Pain Reconceptualization, Neuroscience Education, Pain Neuroscience Education, Explain Pain, Pain Neurophysiology Education, and Therapeutic Neuroscience Education.
2. Saragiotto BT, Maher CG, Moseley AM, Yamato TP, Koes BW, Sun X, Hancock MJ. A systematic review reveals that the credibility of subgroup claims in low back pain trials was low. J Clin Epidemiol. 2016 Nov;79:3-9.
6. Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011 Dec;92(12):2041-56.
7. Watson JA, Ryan CG, Cooper L, Ellington D, Whittle R, Lavender M, Dixon J, Atkinson G, Cooper K, Martin DJ. Pain Neuroscience Education for Adults With Chronic Musculoskeletal Pain: A Mixed-Methods Systematic Review and Meta-Analysis. J Pain. 2019 Oct;20(10):1140.e1-1140.e22.
8. Rufa A PT, DPT, OCS, Beissner K PT, PhD, Dolphin M PT, DPT, MS, OCS. The use of pain neuroscience education in older adults with chronic back and/or lower extremity pain. Physiother Theory Pract. 2019 Jul;35(7):603-613.
9. Wood L, Hendrick PA. A systematic review and meta-analysis of pain neuroscience education for chronic low back pain: Short-and long-term outcomes of pain and disability. Eur J Pain. 2019 Feb;23(2):234-249.
10. Tegner H, Frederiksen P, Esbensen BA, Juhl C. Neurophysiological Pain Education for Patients With Chronic Low Back Pain: A Systematic Review and Meta-Analysis. Clin J Pain. 2018 Aug;34(8):778-786.
11. Ryan CG, Gray HG, Newton M, Granat MH. Pain biology education and exercise classes compared to pain biology education alone for individuals with chronic low back pain: a pilot randomised controlled trial. Man Ther. 2010 Aug;15(4):382-7.
12. Louw A, Diener I, Landers MR, Zimney K, Puentedura EJ. Three-year follow-up of a randomized controlled trial comparing preoperative neuroscience education for patients undergoing surgery for lumbar radiculopathy. J Spine Surg. 2016 Dec;2(4):289-298.
13. Traeger AC, Lee H, Hübscher M, et al. Effect of Intensive Patient Education vs Placebo Patient Education on Outcomes in Patients With Acute Low Back Pain: A Randomized Clinical Trial. JAMA Neurol. Published online November 05, 201876(2):161–169.