The Next Path for Pain Neuroscience Education

Intro

Pain Neuroscience Education (PNE) also known as Therapeutic Neuroscience Education has boomed in physical therapy and medical literature in the past 5 years. Many who have been in the trenches writing and researching this topic are finally seeing their seed start to blossom into a tree. To shed some light relative to the rise of chronic pain pathologies, the phrase “pain management” searched in Google has increased 33% in the United States since 2012.

Initially, this was basic science, which did not have a clear-cut way to convey messages in the clinic. Since its’ beginnings, physical therapists have taken the forefront of PNE, finding practical ways of integration into clinical situations. Over the years scientists and clinicians have developed PNE to include handouts, books, and even videos explaining pain and its mysterious nature (1, 2).

It seems that MOST who provide PNE use it primarily as a tool for patients they believe will benefit from education on how pain works (e.g. chronic pain, hyperalgesia, central sensitization, insert any pain nomenclature here – not an exhaustive list). These clinicians provide some level of pain literacy during sessions at various moments of “best fit”. I believe there may be a better, more purposeful, and more specific use of our time spent educating patients.

We will now begin discussing what may be a novel market for PNE, based on evidence. Louw et al., 2013 pioneered a study on PNE provided with the same purpose, but in a different context (3). Instead of treating the problem post hoc, Louw and colleagues intervened earlier along the timeline. This aligns with goal setting to create a realistic understanding of outcomes, a benchmark to compare with, and a mutual respect for the waxes and wanes that occur with the brain’s output of pain.

How_Brain_Processes_Pain
Credit: Sean Mackey, Stanford University

Purpose

Louw et al., 2013 formulated a protocol for a 30-minute PNE session and created a PNE booklet to be used pre-operatively in patients with lumbar radiculopathy (3). The researchers hypothesis was that altering pre-operative education would improve post-surgical outcomes. They state that there are many issues with postoperative rehabilitative care, including little effect on reducing disability and pain and a subsequent lack of surgeon referral (pg. 447). We know that patients want more information about their surgeries, and they rarely have accurate expectations or understanding of what the outcomes will be (4). They also want to know and understand how pain works and its’ inexplicable reaction to changes in the body (5).

A total 97% of preoperative programs prior to this study were using pathoanatomical and biomechanical models for pain, which is generally what a surgeon’s training is based upon (6; 7; 8). This method is a contradiction to what our Low Back Pain Clinical Practice Guideline from Delitto et al., 2012 recommend (9).

With Grade B evidence, they state the following:

“Clinicians should NOT utilize patient education and counseling strategies that either directly or indirectly increase the perceived threat or fear associated with low back pain, such as education and counseling strategies that: 1. promote extended bed-rest or 2. provide in-depth, pathoanatomical explanations for the specific cause of the patient’s low back pain. Patient education and counseling strategies for patients with low back pain should emphasize: 1. the promotion of the understanding of the anatomical/structural strength inherent in the human spine, 2. the neuroscience that explains pain perception, 3. the overall favorable prognosis of low back pain, 4. the use of active pain coping strategies that decrease fear and catastrophizing, 5. the early resumption of normal or vocational activities, even when still experiencing pain, and 6. the importance of improvement in activity levels, not just pain relief.”

Educating based on pathoanatomical principles are known to be ineffective (10) and even have the capacity to increase fears and anxieties, thereby negatively impacting outcomes (11; 12; 13). Louw and colleagues seemed to understand this concept early. They also are the first to my knowledge to have performed an RCT with long term followup based on a pre-operative education model. Finally, they attempted to answer whether understanding how pain works under a biopsychosocial approach combined with standard care would improve outcomes.

 

Procedure

One on one education sessions were performed based on messages in line with a prior systematic review (14). The authors described their content with main messages consisting of:

  • The neurophysiological basis of pain
  • Nociception and nociceptive pathways
  • Neurons
  • Synapses
  • Action potentials
  • Spinal inhibition and facilitation
  • Peripheral sensitization
  • Central sensitization
  • Plasticity of the nervous system
  • NO references to emotional aspects of pain
  • NO references to anatomical models of pain

Key factors included concepts about pain output rather than nociceptive input. For instance, the nervous system can increase or decrease sensitivity based on what it believes may be best for coping and levels of stress (15; 16). Subjects were also educated that pain is likely a better indicator of threat than true tissue health as noted previously in literature (17; 18).

After education sessions, patients were provided a booklet, which was similar to the style of the Explain Pain book (1). It was divided into 6 sections including: “the decision to have back surgery; the nervous system anatomy, physiology, and pathways; peripheral nerve sensitization; environmental influences on nerve sensitivity; down-regulation of the nervous system; and recovery after back surgery” (pg. 448) (3).

onion
Credits: Onion Skin Model, Moseley & Butler, 2003

Implementation

A thirty-minute session (within 1 week of surgery) of PNE plus the booklet and usual care was compared to usual care in sixty-seven patients scheduled for surgery due to lumbar pain with radiculopathy (19). The hopes of this intervention were to both improve post-surgical outcomes and reduce the 10-40% of persons who have residual pain, loss of movement, and disability after lumbar spine surgery (20).

They were measured at baseline, 1, 3, 6, and 12 months post operatively on low back pain (numeric rating scale), leg pain (numeric rating scale), function (Oswestry Disability Index), various beliefs and experiences related to LS (10-item survey with Likert scale responses), and postoperative utilization of health care (utilization of health care questionnaire). If you are interested in further details of the methodology, please review the original paper. Some exclusion criteria that should be noted was: 1. Patients < 18 or > 65, 2. evidence of spinal cord compression, 3. undergoing lumbar spine surgery for a condition other than radiculopathy. A priori power analysis was performed and the researchers did meet minimum requirements despite some dropout due to loss of follow-up (19).

Post surgery

Trends were noted at 3 months favoring the PNE group, but no significant differences were noted at 1, 3, or 6-month follow-ups. Similar levels of pain and dysfunction were noted between both groups at 12 months as well. The authors then measured healthcare utilization by asking patients, “to indicate if they had any, and how many, additional of the following medical tests specifically related to their postoperative care: radiographs (X-ray); magnetic resonance imaging (MRI); computerized tomography (CT); bone scan; nerve conduction test (NCT); myelogram; and/or, other medical tests. Additionally, patients were asked to report if they had received any post-surgical treatment or attended for consultations with their spine surgeon; family doctor; physical therapist; other specialist physicians; chiropractor; massage therapist; acupuncturist; psychologist; psychiatrist; and/or, other healthcare professionals” (21, pg. 292) At one-year post lumbar surgery, the PNE group spent 45% less healthcare dollars on medical tests and treatments. The authors report that this was equal to greater than $2,000 saved per patient based on estimates from the Center from Medicare/Medicaid Services Fee Schedule. This is in contrast to other studies, such as Morris et al., who saw no difference (18). The authors concluded that their study might have differed because they added a one on one 30-minute PNE session along with a booklet PRIOR to surgery, whereas Morris et al., offered only a booklet AFTER surgery. Finally, the subjects who received PNE reported a more favorable view of their surgery including higher scores on a likert scale of: “fully prepared for surgery”, “preoperative education prepared me well”, and “met expectations”.

A second RCT was conducted with the purpose of a 3-year follow-up of these same subjects (22). This is likely to be an appropriate measure of retention, as true behavior changes take are said to take place in 6 months to 5 years duration (24, 24). The purpose of this was to re-assess retention and to see the trend of healthcare utilization. A 3-year follow-up was performed on 50 patients of the original 61 from the 1-year follow-up RCT. The results showed that 16/50 (10 from PNE group, 6 from usual care) patients had no further healthcare utilization. Three patients from the control group and one patient from the PNE group required a second surgery as well. The authors reported that total medical expenses were cumulatively 37% lower for the PNE group than for the usual care group. Over the three years post operatively, the expenses were devoted primarily to lower utilization of physician visits, physical therapy, and massage (pg. 293). The same three post-operative satisfaction questions listed in the paragraph above retained a statistically significant difference with the PNE group being more favorable than the usual care group (pg. 294) (22).

What Does This Mean

We are aware that it is not uncommon for persons who receive lumbar spine surgery to have some pain for the rest of their lives. If we can teach messages to patients such as pain is normal and everyone has it and SHOULD feel it, then they may feel more comfortable with their outcomes. The results of these studies show that changing perception prior to a spinal surgery for lumbar radiculopathy may provide favorable results, specifically speaking in terms of healthcare dollar savings. Definitive conclusions cannot yet be made, especially due to under powering of the 3-year follow-up, but we can hope that reproduction of studies such as these show similar results.

Where Does Physical Therapy Fit Into This

This model of education was designed specifically for Physical Therapists to provide prior to surgery. It can be argued that we are the best for this intervention based on the amount of time that will be spent with the patient post-operatively. Improving therapeutic alliance and having an understanding of the patient’s baseline may also play a factor in the improved outcomes found at 1 and 3-year follow-ups. This alliance may be a part in the reduced healthcare dollars spent in the PNE group on overall Physical Therapy visits as well. Despite thorough reporting, the authors do not break down the total dollars per discipline – just the fact that each reached statistical significance. It may be possible that spending more on the front end will save insurers more on the back end of care. As a speculation, it is likely Physical Therapy did not take up a majority of the 45% savings at 1-year and 37% savings at 3-years.

Applying this to the marketing of our profession as a whole, I believe that this is the line of reasoning which should be used for the PT1st campaign. Scientifically reinforcing what we are the best at, rather than just stating that we are the best, is a major key for public perception. This will also help us gain acceptance by other healthcare providers such as surgeons, primary care physicians, sports medicine specialists, and more.

Is this something that you would market to physicians for referral or more integrated care? Can we present evidence such as this to insurance companies to prove our value as a low-cost healthcare provider (granted future studies provide similar results)? Do you believe that this type of intervention will result in less post-operative visits and greater satisfaction outcomes?

If Physical Therapists were to market this, a protocol would be required. There have been more specific studies published that provides the exact phrases and procedural terminology used during PNE sessions. This will be discussed in later posts. Until then though…

 

Thank you for reading,

-Jared Burch, PT, DPT

 


References:

  1. Butler D, Moseley G: Explain Pain. Adelaide, Australia: Noigroup, 2003
  2. Zimney, K., Louw, A., & Puentedura, E. J. (2014). Use of Therapeutic Neuroscience Education to address psychosocial factors associated with acute low back pain: a case report. Physiotherapy theory and practice30(3), 202-209.
  3. Louw, A., Butler, D. S., Diener, I., & Puentedura, E. J. (2013). Development of a preoperative neuroscience educational program for patients with lumbar radiculopathy. American Journal of Physical Medicine & Rehabilitation92(5), 446-452.
  4. McGregor AH, Burton AK, Sell P, et al: The develop- ment of an evidence-based patient booklet for patients undergoing lumbar discectomy and un-instrumented decompression. Eur Spine J 2007;16:339Y46
  5. Louw A, Louw Q, Crous LCC: Preoperative education for lumbar surgery for radiculopathy. S Afr J Physiother 2009;65:3Y8
  6. Brox JI, Storheim K,Grotle M, et al:Systematic review of back schools, brief education, and fear-avoidance training for chronic low back pain. Spine J 2008;8:948Y58
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  9. Delitto, Anthony et al. “Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association.” The Journal of orthopaedic and sports physical therapy4 (2012): A1–57. PMC. Web. 25 May 2017.
  10. Brox JI, Storheim K, Grotle M, et al. Systematic review of back schools, brief education, and fear-avoidance training for chronic low back pain. Spine J 2008;8:948–58.
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  15. Van Oosterwijck J, Nijs J, Meeus M, et al: Pain neu- rophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: A pilot study. J Rehabil Res Dev 2011;48:43Y58
  16. Moseley GL, Brhyn L, Ilowiecki M, et al: The threat of predictable and unpredictable pain: Differential ef- fects on central nervous system processing? Aust J Physiother 2003;49:263Y7
  17. Moseley GL, Nicholas MK, Hodges PW: Does antici- pation of back pain predispose to back trouble? Brain 2004;127(pt 10):2339Y47
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  19. Louw A, Diener I, Butler DS, et al: The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil 2011;92:2041Y56
  20. Louw, A., Diener, I., Landers, M. R., & Puentedura, E. J. (2014). Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up. Spine39(18), 1449-1457.
  21. Ostelo RW, de Vet HC, Vlaeyen JW, et al: Behavioral graded activity following first-time lumbar disc surgery: 1-year results of a randomized clinical trial. Spine 2003; 28:1757Y65
  22. Louw, A., Diener, I., Landers, M. R., Zimney, K., & Puentedura, E. J. (2016). Three-year follow-up of a randomized controlled trial comparing preoperative neuroscience education for patients undergoing surgery for lumbar radiculopathy. Journal of Spine Surgery2(4), 289-298.
  23. Morris S, Morris TP, McGregor AH, et al. Function after spi- nal treatment, exercise, and rehabilitation: cost-effectiveness analysis based on a randomized controlled trial. Spine 2011;36: 1807–14.
  24. Prochaska JO, Velicer WF. Behavior Change: The transtheoretical model of health behaviour change. American Journal of Health Promotion 1998;12:38-48.
  25. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1997;12:38-48.

 

Credits Featured Photo: Nature.com

 

 

 

 

 

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