Pain Neuroscience Education (PNE)

Aims

To increase the awareness and understanding of the role of pain neuroscience

education in the management of patients with chronic low back pain (LBP), by
providing information and resources to its current use clinically. This resource is
primarily aimed towards physiotherapists and student physiotherapists, using a
combination of visual and textual resources.

Learning objectives:

1. To gain an understanding of the history and development of Pain Neuroscience

Education (PNE) as a therapeutic concept.
2. To develop a greater understanding of PNE; what it is and how it is used in clinical
practice
3. To develop an understanding of how PNE is currently being taught to student and
qualified physiotherapists
4. To gain increased awareness of the evidence base available and the applicability of
the findings to clinical practice

Introduction

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). However study
data was only drawn from one area of the United Kingdom, including 100,000 patients,
thus this area may not be generalisable to the United Kingdom as a whole.
Furthermore the study only considered patients reporting their pain to a General
Practitioner, so only measured patients who seeking health care advice thus failed to
consider the whole population suffering LBP (Jordan et al., 2010). Further to this, 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.

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).

What is Pain Neuroscience Education (PNE)?

Pain neuroscience education (PNE), also known as therapeutic neuroscience

education (TNE), consists of educational sessions for patients describing in de tail the
neurobiology and neurophysiology of pain and pain processing by the nervous system
(Louw, Diener, Butler and Puentedura. 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
(Clarke, Ryan and Martin. 2011). 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, Girbés, Lundberg, Malfliet and Sterling. 2015).
Therefore, a deeper level reasoning and treatments beyond a medical model is
required.
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).

What is central sensitisation?

Central sensitisation is a neural condition developing from plastic changes that occur
within the central nervous system (spinal cord), causing the manifestation of chronic
pain (McAllister, 2012). Theory of central sensitisation explains t hat spinal neurons
are in state of hyperexcitability with lower nociceptive threshold (Sciable and Richter,
2004). Additionally, peripheral inputs from not only A δ and C fibres but also
innocuous Aβ mechanoreceptor fibres of injured and adjacent non-injured tissues,
increase summation of action potentials at the dorsal root ganglion as pictured below:
Figure 4:Systemic effects of central sensitisation (McAllister, 2012)

These plastic changes cause a state of persistent hyper-sensitivity to develop, even

after tissue healing has occurred. Thus the patient continues to experience pain, even
with less provocation (McAllister, 2012). The theory of central sensitisation was
highlighted in the 1960’s, when the pain gate theory advocated that the sensory relay
system could be modulated by inhibitory controls (pressure) (Woolf, 2011).
Central sensitisation also involves changes in the brain at cellular level (McAllister,
2012) ). However other research has suggested that sensitisation may develop from:
activity-dependant synaptic plasticity, gap junctions, astrocytes, membrane excitability
and gene transcription (Woolf, 2011).
Whilst it has long been recognised that Strokes and Spinal Cord injuries can cause
central sensitisation, it is not fully understood why it may develop following
musculoskeletal injury (McAllister, 2012). However it has been proposed that there
may be one of two reasons for its development, although there is no conclusive
evidence to support this (McAllister, 2012):
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 sensitation

History of pain models and development of PNE

Where has PNE developed from?

The biomedical model is most commonly used by physiotherapists and other medical
health professionals for the management of pain (Louw, 2014 & 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).

Figure 1: Cartesian theory of pain stating that pain to the brain is a “straight
line” (Lower-back-pain-toolkit.com, 2015)

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 (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 t he 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)
 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 (Linton, 2005).
Clinicians frequently use 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).

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 people with horrific injuries felt either no or a low intensity of pain
(Melzack, Wall & 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
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 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.

How does this affect clinicians in practice?

Investigations by the Therapeutic Neuroscience research team at the ‘Internat ional

Spine and Pain Institute’ has discovered that people in pain are interested in pain and
more specifically the mechanisms of pain (Louw A, Louw Q & Crous LC. 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.
What does PNE consist of / 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 (louw et al., 2011).

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 (Clarke et
al., 2011).

Figure 6. showing the content of PNE education sessions with patients (Louw et al.,
2011)
How is PNE used in clinical practice?

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., (2014) in
clinical practice to teach patients about complex pain physiolog y 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 (Louw et al., 2014). 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.

Indicators for the use of PNE

Chronic musculoskeletal conditions (Moseley, 2015)

Figure 7. (right): showing chronic MSK conditions with positive PNE results from
current evidence (Moseley, 2015)
 These conditions are often characterized by brain plasticity that leads to
hyperexcitability of the central nervous system (central sensitization).
 PNE is recommended in
central sensitization conditions like these,
as the patient may present with maladaptive
cognitions, behavior, 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 (Louw, Diener, Landers, 2014) and
(Zimney, Louw, Puentedura et al., 2014).

The benefits and drawbacks of PNE

 Table 1: showing the benefits and drawbacks of PNE adapted from (Louw et al.,2014),
(Moseley, 2003) and (Moseley, 2004)

Benefits Drawbacks

RCT's have shown a reduction in fear and catastrophizing, due Evidence suggests PNE alone is not a viable
to the immediate effect of PNE on improving attitudes and intervention for pain and disability
beliefs about pain.

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:

Figures 8 - 10: left to right are Positron emission tomography (PET), magnetic
resonance spectroscopy (MRS) and functional magnetic resonance imaging (fMRI) of
pain. (Sharma, Brooks, Popescu et al., 2012; Cole, Farrell, Duff et al., 2006; Casey,
Morrow, Lorenz et al., 2001).

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 reltaed 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 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: row 1 - patient relaxing. Note no red areas.

Figure 12: row 2 - 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.

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.

(Louw A, et. al 2014 – submitted for publication)

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 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?
Current training provided in PNE

Firstly it is presumed that PNE as a first line cognitive behavioural therapy can be
implemented by any healthcare professional. Zimney, Louw and Puentedura (2013)
explain that the key to successfully using PNE, is to provide timely intervention for
only those patients that present with both pain and maladaptive cognitive pain
behaviours together. This requires a level of understanding of pain
mechanisms, yellow flags and blue flags. Health professionals are in a prime position
to deliver PNE, as they are the first point of contact for patients that are experiencing
health concerns exceeding their own capability to self-manage.

Undergraduate training

PNE is not currently delivered in undergraduate courses for medical or physiotherapy

professions and there is an obvious lack of understanding of the non-tissue related
causes of pain, and its appropriate management. The table below demonstrates the
undergraduate stance on understanding of chronic pain management at time of
reporting in 2009. This was assessed by way of questionnaires provided to third year
physiotherapy and medical students.

Table 2. Results from questionnaire of medical and physiotherapy students chronic

pain knowledge (Ali and Thomson, 2009).
 The box and whisker plots in figure 14 illustrate the differences between medical and
physiotherapy students in management and knowledge of chronic pain.

Figure 14. Box and whisper plots to visually demonstrate variances in knowledge of
chronic pain and it's management (Ali and Thomson, 2009).

Postgraduate training

Despite the lack of pre-qualifying training, health professionals are expected to

subjectively flag up maladaptive pain behaviours and teach coping strategies.
Neuroscience education is currently perceived as a speciality and is delivered as a
post graduate masters degree or PhD. However in recent years, delivery of pain
neuroscience courses provided by private organisations have become available.
These courses are taught by clinical specialists and provided by organisations such
as Physio Uk’s Know Pain course, advertised recently on the CSP website. This is a
2 day workshop open to anyone supportinga chronic pain patient, with a programme
including:

 How to apply teaching skills within a practice setting

 The Neurology of Pain
 Facilitating Pain Education
 The Language of Pain
 Pain and the affected mind
 Getting Going Again
 Case Studies

The course tutor, Mike Stewart (MCSP) is a Clinical Specialist Physiotherapist and
explains his journey to becoming a specialist in chronic pain within his podcast.

Another course provider the Neuro Orthopaedic Institute (NOI) solely teach health
professionals in their ‘Explain pain’ programme, with aim to:

 Expand the clinical framework of rehabilitation via the paradigms of neuromatrix and
pain mechanisms.
 Teach biologically based pain management skills under a framework of the sciences of
clinical reasoning and evidence from clinical trials, neurobiology and education
research.
 Reconceptualise pain in terms of modern neuroscience and philosophy.
 Stimulate an urgent reappraisal of current thinking in rehabilitation, with benefits for all
stakeholders in clinical outcomes - the patient, the therapist, the referrer and the payer.
 Teach the core pain management skills of neuroscience education.

As has been discussed above, there is inter-professional variability in delivery of

undergraduate chronic pain education. Additionally, there is variability in structure and
content of neuroscience education courses.

Critical appraisal of the evidence:

Paper 1:The Effect of Neuroscience Education on Pain, Disability, Anxiety, and

Stress in Chronic Musculoskeletal Pain

A recent systematic review investigating the benefits of pain neuroscience education

(PNE), discovered that PNE significantly decreased pain, pain catastrophization 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.

Paper 2: Preoperative Pain Neuroscience Education for Lumbar Radiculopathy

(Louw, Diener, Landers, 2014)
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.

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 2011, investigated the impact of PNE, specifically on that
management of patients with chronic low back pain.
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.

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.
Paper 4:Use of therapeutic neuroscience education to address psychosocial
factors associated with acute low back pain: a case report (Zimney, Louw,
Puentedura et al., 2014)

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.

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 poo r 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.

Summary of current concepts of PNE

 Pain neuroscience education is a 21st century concept that is based on the

biophyscosocial model of pain that aims to reconceptualise how patient's percieve their
pain.
 The belief is that the likelihood of chronic pain may not by caused by unhealthy tissue
but brain plasticity leading to central sensitisation.
 PNE consists of educational sessions for patients describing in detail the
neurophysiology of pain and pain processing by the nervous system.
 Evidence on PNE for chronic and acute low back pain shows promising improvements
in pain catastrophizing, perceived disability and short term pain relief.
 However, the research is immature at this stage as there are few studies available and
not of a high enough methodological quality to give recommendations for clinical
practice.

Resources:

1) Podcast - Chews health podcast SESSION 4 – KNOW PAIN: METAPHORIC EXPRESSION WITH MIKE
STEWART –PART 1, PART 2

2) Educational course - Know Pain course: A Practical guide for Therapeutic Neuroscience Education,
course providerdiscussion
3) Youtube video - Lorimer Moseley Pain - How to Explain Pain to Patients, click here:video

4) Professional Forum- iCSP forum discussion on clinicans views of using PNE. CSP Membership required, click
here: www.csp.org.uk/icsp/topics/neuroscience-based-pain-education-resounding-success-or-damp-squib

5) Educational Course Leaflet - Know Pain course: A Practical guide for Therapeutic Neuroscience Education,
course provider discussion (transcription) Explain Pain – Patient Leaflet

6) Book - Why Do I Hurt? Adriaan Louw (Available online)

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