Jospt 2021 9804

Title: Revisiting the provision of Pain Neuroscience Education: An adjunct intervention for
patients, but a primary focus for clinician education
Authors:
Downloaded from www.jospt.org at Asociación de Kinesiología del Deporte (AKD) on October 30, 2020. For personal use only. No other uses without permission.
Adriaan Louw, PT, PhD

Story City, IA
Kathleen A. Sluka, PT, PhD, FAPTA

University of Iowa
Iowa City, IA
Jo Nijs, PT, PhD

Vrije Universiteit Brussel
Brussels, BE
Carol A. Courtney, PT, PhD

Northwestern University
Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Chicago, IL
Kory Zimney, PT, DPT

University of South Dakota
Vermillion, SD
Conflict of interest:
Dr. Adriaan Louw teaches for a post-professional educational company for which he receives
Journal of Orthopaedic & Sports Physical Therapy®
honorariums he has also published books on Pain Neuroscience Education for which he receives
royalties.
Dr. Kathleen Sluka serves as a consultant for GSK Consumer Health, has research funding from
Pfizer, Inc., and receives royalties from IASP Press.
Dr. Jo Nijs has authored a Dutch book on pain neuroscience education, but the royalties are
collected by the Vrije Universiteit Brussel and not him personally.
Dr. Carol Courtney has no affiliations with or financial involvement in any organization or entity
with direct financial interest in the subject matter discussed in the article.
Dr. Kory Zimney teaches for a post-professional educational company for which he receives
honorariums he has also published books on Pain Neuroscience Education for which he receives
royalties.
Corresponding Author:
Kory Zimney
414 E. Clark St.
Word count: 1744

Vermillion, SD 57069
Kory.zimney@usd.edu
Revisiting the provision of Pain Neuroscience Education: An adjunct intervention for patients, but a
primary focus for clinician education
1 Abstract:
2 Society is mired in a serious health care crisis regarding the pain and opioid epidemics. Pain
3 neuroscience education (PNE) has gained support in the last 20 years as an intervention to help
4 people manage their chronic pain condition. In this Viewpoint, we argue exercise and
5 movement must be the primary intervention for chronic pain conditions, and PNE or other
6 adjunctive therapies should only be used if they can foster increased exercise and movement
7 participation by the patient. The only time pain education should be the primary focus of a
8 chronic pain management strategy is with students and clinicians to help advance knowledge
9 and skills regarding pain to ultimately enhance care and outcomes for patients.
10 [Viewpoint Text]
11 There is a growing awareness among health professionals, including the physical therapy
12 profession, that management of chronic pain is an unmet need. In the US, release of the Institute
13 of Medicine report in 2011 increased awareness of chronic pain as a national problem and led to
14 development of a National Pain Strategy in 2016. Patient and provider education about pain is
15 one component of an overall management strategy for chronic pain.
16 The International Association for the Study of Pain (IASP) curriculum guidelines (www.iasp-
17 pain.org) were released in 2012 and developed in parallel with pain education competences for
18 all entry level healthcare professionals.1 These guidelines and competencies were adopted in
19 2018 by the House of Delegates of the American Physical Therapy Association (APTA) in an effort
20 to bolster appropriate education on pain, in physical therapy curriculum. These guidelines
1
21 emphasize a biopsychosocial model of pain, and multidisciplinary treatment as central to
22 effective management.
23 While clinicians understand the need for better pain management, implementation of evidence-
24 based pain management guidelines into practice has been slow. One intervention used in clinical
25 practice is pain neuroscience education (PNE). Historically, especially in orthopedic practice, pain
26 was often correlated to tissue injury. Pain, especially persistent pain, is more complex than simply
27 a biological explanation. PNE evolved as an educational intervention explaining these complex
28 biological processes to patients in easy-to-understand metaphors, examples, and pictures, as a
29 means to alter a patient’s beliefs regarding their pain and reducing threat.
30 Reconceptualizing how pain works should change pain beliefs, decrease fear-avoidance, and pain
31 catastrophizing. In turn, reducing pain and disability. In this viewpoint, we argue against using
32 PNE as a stand-alone treatment intervention for individuals with persistent pain. Physical
33 therapists must focus on movement and use PNE, along with other adjunct interventions, to
34 facilitate a movement-based approach.
35 Does Pain Neuroscience Education Work?
36 Despite clinically meaningful improvements in fear of movement and pain catastrophizing,
37 changes in pain and disability were not clinically important when PNE was provided as a stand-
38 alone treatment.2,3 Education-as-a-stand-alone treatment has minimal effects on chronic pain.
39 These findings align with the National Pain Strategy and current clinical practice guidelines
40 suggesting exercise and movement should be first-line treatments. PNE was never intended as
41 stand-alone treatment. PNE fits within a biopsychosocial framework complementing other
2
42 multimodal interventions. We argue that PNE should not be the focus of treatment, but rather
43 used as an adjunct intervention to promote exercise and movement. Movement therapies have
44 some favorable evidence of effectiveness for reducing pain and psychological co-morbidities, and
45 improving function and quality of life.
46
47 Exercise and movement should be first-line management for persistent pain
48 The evidence behind exercise in general for persistent pain is promising in many areas. Exercise
49 and increased physical activity not only improve function, but also modify nociceptive,
50 neuropathic, and nociplastic pain.4 The mechanisms of how exercise reduces pain have been
51 extensively studied in preclinical studies, and includes activation of endogenous inhibitory
52 systems in the central nervous system (opioids and serotonin), reduction in central excitability,
53 altered ion channel expression on nociceptors, promotion of tissue healing, and modulation of
54 the immune system. These mechanisms may explain the clinical findings of hypoalgesia and
55 improved outcomes with exercise. While further research needs to establish appropriate dosage
56 and best types of exercise for various persistent pain cases, it is clear movement is key.
57
58 People in pain are reluctant to move, and many have significant increases in pain with exercise.4
59 The clinician has a range of adjuncts available that might help to facilitate exercise. Although the
60 results of clinical trials for Transcutaneous Electrical Nerve Stimulation (TENS) have been variable,
61 a recent high-quality trial showed clinically meaningful reductions in movement-evoked pain for
62 those with persistent pain.5,6 TENS still may be a safe, affordable, self-management tool that
63 relieves pain during movement and exercise via activation of central inhibitory pathways and
3
64 reduction of central sensitization.5 Manual therapy can also inhibit pain by activating endogenous
65 inhibitory pathways, and may serve as an adjunct to facilitate movement and exercise.7
66
67 Clinicians should be cautious when using passive interventions, especially with people who have
68 low self-efficacy, as they may strengthen patients’ biomedical beliefs about pain (i.e. that the
69 source of pain needs to be fixed). Therefore, we encourage clinicians to think of PNE, TENS, and
70 manual therapy as tools to help facilitate a movement-based approach.
71
72 Where does Pain Neuroscience Education fit in clinical practice?

73 As we pointed out, PNE has little to no meaningful effect on pain as a stand-alone treatment.
74 However PNE, when combined with movement (i.e., exercise), may provide superior results
75 compared to PNE alone.3 In a recent randomized clinical trial, PNE alone did not yield any
76 meaningful changes for patients having chronic spine pain after the educational process.8 The
77 PNE group, however, had clinically meaningful improvements in pain disability and pain
78 cognitions when cognition-targeted exercise therapy was added. Because PNE can alter fear of
79 movement and pain catastrophizing, it could be an additional tool for patients with high fear-
80 avoidance behaviors or pain catastrophizing, which are common barriers for initiating and
81 adhering to exercise therapy in patients having persistent pain. These studies continue to
82 reiterate the original intent that PNE is not stand-alone treatment. The goal of PNE is not for the
83 patient to know more about pain, but to feel safer to increase activity through exercise, daily
84 tasks, work, or socializing.
85
4
86 The role of Pain Neuroscience Education in education curriculum
87 If there is any role for stand-alone pain education, it might be for the clinician, not the patient.
88 There is a great need to improve curriculum content in entry-level physical therapy programs and
89 pain science education for practicing clinicians. Physical therapists are front line pain
90 management providers, yet there is limited curriculum content directly related to this in physical
91 therapy education programs.9 The IASP curriculum guidelines and pain competencies, adopted
92 by the APTA, provide a comprehensive structure and guide for entry-level education of physical
93 therapists. Apart from a basic lack of knowledge of pain, especially modern concepts of pain, the
94 clinician’s attitudes and beliefs regarding pain may be another reason why treating persistent
95 pain may be so challenging. Improving clinician knowledge about pain may foster enhanced
96 therapeutic alliance with patients.
97 Pain education for various healthcare providers, including physical therapists and physical
98 therapy students was associated with significant improvements in knowledge of pain, positively
99 shifted attitudes and beliefs regarding persistent pain, and influenced clinical practice.10 Full
100 implementation of the pain curriculum guidelines within educational programs is lacking, and
101 studies exploring effective teaching strategies and pedagogy on the delivery of pain curriculum
102 are limited. If there is any role for a primary pain education-alone strategy to combat the pain
103 epidemic, it may be with educating clinicians.
104 Change ahead
105 Changing the pain and opioid epidemics along with improving care is complex. Effective
106 partnerships and collaborations within clinical practice, and within the broader community are
5
107 critical to improving clinician education. The APTA has formed a partnership with the IASP to
108 promote and enhance interprofessional pain education of physical therapy educators. The goal
109 is to improve implementation and provide resources to clinicians. Removing barriers and biases
110 along with being open to change and collaboration will be critical to successful improvement of
111 pain education of the physical therapy curriculum and clinicians.
112
113 Substantial national efforts to improve the science, education, and management of pain have
114 been adopted in the last several years; physical therapists will need to embrace and integrate
115 these efforts to improve care for those suffering with persistent pain. The profession will need to
116 employ the current management techniques using the strongest evidence as a first-line approach
117 to treatment, i.e. movement/exercise therapy, and a variety of self-management approaches to
118 improve chronic pain management. Treatments such as PNE, TENS, and manual therapy can be
119 used by physical therapists as adjuncts to help facilitate movement as the primary pain-relieving
120 strategy for the individual with chronic pain.
121
122 A multimodal approach to pain, focused on movement, could be used as a self-management
123 approach to reduce reliance on pharmaceutical agents and facilitate improved overall health.
124 Physical therapists are movement experts and are thus ideally suited to provide first-line
125 treatment with exercise. However, we must also appreciate the multidimensional nature of pain
126 and a multidisciplinary approach to pain management is more effective than physical therapy
127 alone. Thus, interprofessional collaboration is critical to successful management of individuals
128 with chronic pain, particularly the more complex chronic pain cases.
6
129
130 Pain is complex, and no single profession can always solve persistent pain problems alone. It is
131 time for health care professionals to reach consensus to enhance the use of non-pharmacological
132 and movement-based approaches to managing pain across a multidisciplinary network of
133 healthcare providers. Providers need to increase their understanding of pain, with the ultimate
134 goal to improve outcomes for people with acute and chronic pain.
135
136 Key points
137 • Pain neuroscience education as a stand-alone treatment generates clinically meaningful

138 improvements in fear of movement and pain catastrophizing but is not effective for relieving
139 pain in patients with pain.
140 • Clinicians should focus on movement as the key element of managing persistent pain; adjunct
141 interventions may be used to facilitate movement.

142 • Pain education, when applied to clinicians, may be beneficial to effect change in beliefs and
143 attitudes about pain and improve delivery of evidence-based interventions.
144 • Collaboration and teamwork both within the profession and with our patients will be key to
145 tackling the current pain and opioid epidemics.
146
147 Study Details
148
149 Author contributions: Study Concept/Design: AL had original concept and reached out to collaborators
150 to finalize design (KS, JN, CC, and KZ).
151 Drafting Manuscript: All authors (AL, KS, JN, CC, and KZ) were involved in drafting manuscript.
152 Critical revision of manuscript: All authors (AL, KS, JN, CC, and KZ) were involved in revisions.
7
153 Final approval: All authors (AL, KS, JN, CC, and KZ) signed off on final approval of submitted and revised
154 paper.
155
156 data sharing: there are no data in this manuscript.

157 patient and public involvement: patient/public partners were not involved in this manuscript
158
8
159 References:
160 1. Fishman SM, Young HM, Lucas Arwood E, et al. Core competencies for pain management: results
161 of an interprofessional consensus summit. Pain Med. 2013;14(7):971-981.
162 2. Watson JA, Ryan CG, Cooper L, et al. Pain neuroscience education for adults with chronic
163 musculoskeletal pain: a mixed-methods systematic review and meta-analysis. The Journal of Pain.
164 2019.
165 3. Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on
166 musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract.
167 2016;32(5):332-355.
168 4. Sluka KA, Law LF, Bement MH. Exercise-induced pain and analgesia? Underlying mechanisms and
169 clinical translation. Pain. 2018;159(Suppl 1):S91.
170 5. Dailey DL, Vance CG, Rakel BA, et al. A Randomized Controlled Trial of TENS for Movement‐Evoked
171 Pain in Women with Fibromyalgia. Arthritis & Rheumatology. 2019.
172 6. Gibson W, Wand BM, Meads C, Catley MJ, O'Connell NE. Transcutaneous electrical nerve
173 stimulation (TENS) for chronic pain - an overview of Cochrane Reviews. Cochrane Database Syst
174 Rev. 2019;2:Cd011890.
175 7. Courtney CA, Steffen AD, Fernández-De-Las-Peñas C, Kim J, Chmell SJ. Joint mobilization enhances
176 mechanisms of conditioned pain modulation in individuals with osteoarthritis of the knee. J
177 Orthop Sports Phys Ther. 2016;46(3):168-176.
178 8. Malfliet A, Kregel J, Coppieters I, et al. Effect of pain neuroscience education combined with
179 cognition-targeted motor control training on chronic spinal pain: a randomized clinical trial. JAMA
180 neurology. 2018;75(7):808-817.
181 9. Bement MKH, Sluka KA. The current state of physical therapy pain curricula in the United States:
182 a faculty survey. The Journal of Pain. 2015;16(2):144-152.
183 10. Louw A, Vogsland R, Marth L, Marshall P, Cox T, Landers M. Interdisciplinary Pain Neuroscience
184 Continuing Education in the Veterans Affairs. The Clinical journal of pain. 2019;35(11):901-907.
185
186 Appendix of Recommended Reading References:
187
188 1. Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for
189 chronic pain in adults: an overview of Cochrane Reviews. Cochrane database of systematic
190 reviews. 2017(4).
191 2. Cuenca JJA, Pecos-Martin D, Martinez-Merinero P, et al. How Much Is Needed? Comparison of
192 the Effectiveness of Different Pain Education Dosages in Patients with Fibromyalgia. Pain medicine
193 (Malden, Mass) 2019.
194 3. Malfliet A, Kregel J, Meeus M, et al. Blended-Learning Pain Neuroscience Education for People
195 With Chronic Spinal Pain: Randomized Controlled Multicenter Trial. Physical therapy 2018; 98(5):
196 357-68.
197 4. Moseley GL, Butler DS. Fifteen years of explaining pain: the past, present, and future. The Journal
198 of Pain. 2015;16(9):807-813.
199 5. Collearya G, O’Sullivan K, Griffin D, Ryan C, Martin D. Effect of pain neurophysiology education on
200 physiotherapy students’ understanding of chronic pain, clinical recommendations and attitudes
201 towards people with chronic pain: a randomised controlled trial. Physiotherapy. 2017;103(4):423-
202 429.
9
203 6. Koltyn KF, Brellenthin AG, Cook DB, Sehgal N, Hillard C. Mechanisms of exercise-induced
204 hypoalgesia. The Journal of Pain. 2014;15(12):1294-1304.
205 7. Lima LV, Abner TS, Sluka KA. Does exercise increase or decrease pain? Central mechanisms
206 underlying these two phenomena. The Journal of physiology. 2017;595(13):4141-4150.
207 8. Larsson A, Palstam A, Löfgren M, et al. Resistance exercise improves muscle strength, health
208 status and pain intensity in fibromyalgia—a randomized controlled trial. Arthritis research &
209 therapy. 2015;17(1):1-15.
210
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Title: Revisiting the provision of Pain Neuroscience Education: An adjunct intervention for

patients, but a primary focus for clinician education

Adriaan Louw, PT, PhD

Kathleen A. Sluka, PT, PhD, FAPTA

Jo Nijs, PT, PhD

Carol A. Courtney, PT, PhD

Kory Zimney, PT, DPT

Word count: 1744

15 one component of an overall management strategy for chronic pain.

20 to bolster appropriate education on pain, in physical therapy curriculum. These guidelines

21 emphasize a biopsychosocial model of pain, and multidisciplinary treatment as central to

27 a biological explanation. PNE evolved as an educational intervention explaining these complex

28 biological processes to patients in easy-to-understand metaphors, examples, and pictures, as a

34 facilitate a movement-based approach.

35 Does Pain Neuroscience Education Work?

36 Despite clinically meaningful improvements in fear of movement and pain catastrophizing,

38 alone treatment.2,3 Education-as-a-stand-alone treatment has minimal effects on chronic pain.

41 stand-alone treatment. PNE fits within a biopsychosocial framework complementing other

45 improving function and quality of life.

47 Exercise and movement should be first-line management for persistent pain

51 extensively studied in preclinical studies, and includes activation of endogenous inhibitory

70 manual therapy as tools to help facilitate a movement-based approach.

72 Where does Pain Neuroscience Education fit in clinical practice?

84 tasks, work, or socializing.

86 The role of Pain Neuroscience Education in education curriculum

96 therapeutic alliance with patients.

103 epidemic, it may be with educating clinicians.

104 Change ahead

111 pain education of the physical therapy curriculum and clinicians.

117 to treatment, i.e. movement/exercise therapy, and a variety of self-management approaches to

120 strategy for the individual with chronic pain.

122 A multimodal approach to pain, focused on movement, could be used as a self-management

127 alone. Thus, interprofessional collaboration is critical to successful management of individuals

132 and movement-based approaches to managing pain across a multidisciplinary network of

136 Key points

137 • Pain neuroscience education as a stand-alone treatment generates clinically meaningful

139 pain in patients with pain.

141 interventions may be used to facilitate movement.

143 attitudes about pain and improve delivery of evidence-based interventions.

145 tackling the current pain and opioid epidemics.

156 data sharing: there are no data in this manuscript.

186 Appendix of Recommended Reading References:

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