Therapist: “If you stepped on a rusted nail right now, would you want to know about it?”
Patient: “Of course.”
Therapist: “Why?”
Patient: “Well; to take the nail out of my foot and get a tetanus shot.”
Therapist: “Exactly. Now, how do you know there’s a nail in your foot? How does the nail get your attention?”
Therapist: “The human body contains over 400 nerves that, if strung together, would stretch 45 miles. All of these nerves have a little bit of electricity in them. This shows you’re alive. Does this make sense?”
Patient: “Yes.”
Therapist: “The nerves in your foot are always buzzing with a little bit of electricity in them. This is normal and shows….?”
Patient: “I’m alive.”
Therapist: “Yes. Now, once you step on the nail, the alarm system is activated. Once the alarm’s threshold is met, the alarm goes off, sending a danger message from your foot to your spinal cord and then on to the brain. Once the brain gets the danger message, the brain may produce pain. The pain stops you in your tracks, and you look at your foot to take care of the issue. Does this sound right?”
Patient: “Yes.”
Therapist: “Once we remove the nail, the alarm system should…?”
Patient: “Go down.”
Therapist: “Exactly. Over the next few days, the alarm system will calm down to its original level, so you will still feel your foot for a day or two. This is normal and expected.”
Therapist: “Here’s the important part. In one in four people, the alarm system will activate after an injury or stressful time, but never calm down to the original resting level. It remains extra sensitive. With the alarm system extra sensitive and close to the “firing level,” it does not take a lot of movement, stress or activity to activate the alarm system. When this happens, surely you think something MUST be wrong. Based on your examination today, I believe a large part of your pain is due to an extra-sensitive alarm system. So, instead of focusing of fixing tissues, we will work on a variety of strategies to help calm down your alarm system, which will steadily help you move more, experience less pain and return to previous function.” (10)
This example shows the shift in teaching about pain from a perspective that there is tissue damage to one that enables them to see pain from a sensitive nervous system perspective.
A full program of pain management should include this type of education with exercise and manual therapy. It has been shown that sessions that include education and exercise or manual therapy help remove doubt and develop a deep understanding of her pain experience. (11)
The patient should be encouraged to perform the key exercises to enhance movement as clinically reasoned through the evaluation and exercise portion of the encounter with focus on breathing and relaxation while doing them.(12)
Exercise should be monitored and guided using guidelines from Pain Neuroscience Education. The therapist should guide the patient to move their body or limb to the position at which they report a slight increase in pain intensity, just perceptibly above their baseline intensity. Once there, the patient is instructed to ask two questions: “Is this (movement or position) safe for my physical body?” and “Will I be okay later (if I move this much or stay in this position)?”
With some practice and effort, the patient will find an amount of movement or postural change that feels safe, and that won’t likely flare the pain. At this point the patient is directed to divide their attention between their breath, body tension and the pain. Once aware of these, the patient should be instructed to do their best to keep their breath calm and their muscle tension low, while also attending to the pain, allowing self-monitoring that is unlikely to become hypervigilant or distracted. (13)
Various high quality randomized controlled trials and systematic reviews have shown increasing efficacy of PNE decreasing pain, disability, pain catastrophization, movement restrictions, and healthcare utilization. (12) Physical therapist working with patients with chronic pain should consider use of Pain Neuroscience Education to help this population reach their goals.
References
Moseley GL 2007a Reconceptualising pain according to modern pain sciences. Physical Therapy Reviews 12: 169–178
Butler DS, Moseley LS 2003 Explain Pain. Adelaide, NOI Publications.
Greene DL, Appel AJ, Reinert SE, Palumbo M A 2005 Lumbar disc herniation: Evaluation of information on the internet. Spine 30: 826–829.
Butler DS, Moseley LS 2003 Explain Pain. Adelaide, NOI Publications
Louw, A., Diener, I., Butler, D.S. and Puentedura, E.J., (2011). The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of physical medicine and rehabilitation, 92(12), pp.2041-2056.
Clarke, C.L., Ryan, C.G. and Martin, D.J., (2011). Pain neurophysiology education for the management of individuals with chronic low back pain: A systematic review and meta-analysis. Manual therapy, 16(6), pp.544-549.
Nijs, J., Girbés, E.L., Lundberg, M., Malfliet, A. and Sterling, M. (2015). Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories. Manual therapy, 20 (1), pp. 216-220.
Autio, R. A., Karppinen, J., Niinimaki, J., et al. (2006). Determinants of spontaneous resorption of intervertebral disc herniations. Spine, 31(11), 1247-1252.
Louw A. (2014). Therapeutic Neuroscience Education: Teaching People About Pain
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 Practice 30: 202–209.
Louw A, Zimney K, O’Hotto C, Hilton S. The clinical application of teaching people about pain. Physiother Theory Pract. 2016 Jul;32(5):385-95. doi: 10.1080/09593985.2016.1194652. Epub 2016 Jun 28. Review. PubMed PMID: 27351903.
Blickenstaff, Cory & Pearson, PT, MSc (RHBS), BA-BPHE, Neil. (2016). Reconciling movement and exercise with pain neuroscience education: A case for consistent education. Physiotherapy Theory and Practice. 32. 1-12. 10.1080/09593985.2016.1194653.