Pain neuroscience education (PNE) is a form of education that focuses on teaching people about the neuroscience of pain, including how the nervous system processes and perceives pain.
PNE aims to help people better understand their pain and how it is affected by various factors such as emotions, thoughts, and behaviors.
It is difficult to determine whether the pendulum has swung too far in terms of PNE, as it can be a useful tool in helping people better understand and manage their pain.
Having witnessed the rise of PNE in the world of Physiotherapy in the past 20 years, I can’t help but feel it has almost taken over and created a set a dogmatic clinicians who believe that counseling someone in pain to re-wire their thinking and perception is the holy grail in treatment.
In reality, what PNE focused session looks like is a patient presents to a clinic and is given very little in the way of hands on assessment and treatment. The patient does not feel properly listened to or validated. The patient receives a monologue of ‘pain-splaining’ directed at the patients presumed misdirection beliefs and perceptions. The patient leaves in disbelief and concerned about what exactly is Physiotherapy profession stands for and confused at to what it actually does in terms of adding value to their lives.
This is an obviously extreme example, but hearing from some patients first hand, as well as reading about first person narratives, this theme of patient disillusionment is unfortunately on the rise.
Potential harms of PNE focused approach
In the genuine attempt to help, some clinicians may inadvertently dismiss or minimize a person's pain experiences or symptoms, often by citing research or scientific evidence. This can be harmful to the person experiencing pain, as it can invalidate their feelings and experiences and may cause them to doubt their own perceptions.
Another danger is that it can create a rift between the person in pain and their healthcare provider, leading to a breakdown in the patient-doctor relationship. This can lead to a lack of trust and may make the person in pain less likely to seek medical attention in the future.
Another danger of the PNE focused approach is that it may lead to a lack of appropriate treatment or inadequate care. If a healthcare provider dismisses a person's pain experiences or symptoms, they may not provide the necessary treatment or support, which can lead to a worsening of the person's condition and an increase in their suffering.
Unfortunately we may only see the downstream effects of this approach in the years to come.
If there is enough patient disillusionment I see the Physiotherapy brand at risk, with an increase in mistrust of health care professionals.
So then… what is the current research showing about PNE?
Some of the great hopes about the new pain revolution unfortunately haven’t quite lived up to the initial optimism.
Take the RESOLVE study for example, that stated:
“Central nervous system-directed interventions constitute a completely new treatment paradigm for chronic low back pain management. The results have the potential to be far reaching and change current physiotherapy management of chronic low back pain in Australia and internationally”.
These are some big statements and certainly suggest that there are some big changes coming.
The results of the RESOLVE study weren’t exactly ground-breaking, with only small trend toward a positive impact from PNE.
Another study comparing intensive pain education with placebo in people with acute lower back pain showed no clinical benefit, with authors concluding:
“Adding 2 hours of patient education to recommended first-line care for patients with acute low back pain did not improve pain outcomes. Clinical guideline recommendations to provide complex and intensive support to high-risk patients with acute low back pain may have been premature.”
A new recent paper came out showing no changes in outcome comparing Cognitive Functional Therapy with Manual Therapy and core exercise.
Before you accuse me of being anti-PNE, I am well aware of many promising research around PNE and their is definitely good work being done by good people.
But I feel like the negative studies that don’t support the new paradigm get conveniently swept under the carpet and the sacred PNE narrative largely goes unchallenged, especially by clinicians in Australia, where PNE has dominated through large amounts of government research spending.
I can absolutely see the value in good education around pain mechanisms, but I’m just not sure the public is responding in the positive way we would have hoped.
One of the biggest research papers to ever be conducted on patient perception of PNE was published in recently (Weisman et all 2022) showing,
“People with persistent pain tend to express negative attitudes to PNE statements”.
Another research paper that came out in 2021, co-authored by Lorimer Mosely is quoted as saying,
“It is important to combine PNE with other treatment modalities such as exercise and even manual therapy”.
As this paper importantly suggests, it is important to recognize that PNE is just one aspect of managing pain and that it should be used in conjunction with other approaches, such as physiotherapy and medication, as appropriate.
It’s important to recognize that PNE is not a one-size-fits-all approach and that it may not be suitable for everyone.
Some people may find it helpful in managing their pain, while others may not respond as well.
My belief is that all health care professionals should be highly informed about pain neuroscience and how their own thoughts, beliefs and actions can effect the patient, but we may need to re-evaluate how much specific education we try to impart, based on the needs of the individual in front of us.
For patients, it important to work with a healthcare professional that you trust to determine the most appropriate treatment plan for managing pain.
If something doesn’t feel right, you don’t see any significant improvement or you aren’t getting a combination of effective manual therapy, exercise and education based on your goals, please seek further help elsewhere.
What does the future hold?
I must say a big thanks to Luke Bongiorno and the NOI Team for their recent Masterclass presentation which went into great detail into the relationship between Protection and Performance.
The premise of the Masterclass suggested that Protection and Performance are competing priorities in the body and you need to work on both to get your body to an elite level.
For elite level performance, it is the special coach / athlete relationship that underpins an exploration of pushing the boundary of performance whilst acknowledging the background and sometimes subtle (but occasionally bold) protective strategies is what will ultimately limit the expansion of physical capacity.
It takes work to be able to understand and listen to the language of the Protective system and it is the elite athletes, through time and experience really learn to listen to their bodies. They are experts in their bodies and being able to listen to the relevant signal and ignore the noise.
A great example that springs to mind is the recent Australian marathon record, set by Sinead Diver.
At age 45 and competing in her 14th marathon, Sinead made a few changes to her race build-up, explaining that she tempered her training, for the first time.
Rather than pushing herself to the extreme, this time Sinead was weary of over-training.
Sinead:
“If I felt tired, like on a couple of Sunday’s I had a planned to do a pick up and I just thought…
‘I’m not feeling it today, I need to be careful and know that I don’t have to do it just because it’s on my plan’.
So I think I was a bit smarter during this training block”.
Having full confidence to train hard AND smart is skill that takes years to master, especially for marathon runners.
Importantly, rising to the top isn’t simply about using a ‘no pain, no gain’ approach, but actually respecting the body and allowing periods of plateau or even de-training, accepting that this is a normal part of the process.
To finish, I will leave you with an excellent quote in a review by Adrian Louw:
“In this Viewpoint, we argue against PNE as a stand-alone treatment intervention for individuals with persistent pain.
PNE has little to no meaningful effect on pain as a stand-alone treatment.
Physical therapists must focus on movement and use PNE, along with other adjunct interventions, to facilitate a movement-based approach”.
My vision
I think it is really challenging to try and ‘explain pain’ to people who are already in pain. It can be done, but it does run a real risk of backfiring and damaging the patient-therapist relationship.
A more utopian vision would be to make up to date, evidence informed information knowledge about our bodies function a part of our school curriculum, and we learnt how to take care of them - just like a dentist encourages her clients in oral health.
This would include education about how our bodies work with a focus on ‘use it or lose it’ philosophy and trying to make incidental movement fun and socially engaging. Gamifying movement through innovative use of technology is also a promising development.
In terms of pain education, having read, Pain and Perception book published by NOI, I would love to see this book promoted by local book stores and libraries - specifically for people who aren’t in pain.
Some useful ideas packaged in a fun and innovative way would be a good way to well upstream of our current pain epidemic.
Your thoughts?
I’d love to know your thoughts in the comments below - what has been your experience?