Preoperative Pain Neuroscience Education. Spine Surgery in the US. Disclaimers. Knee OA and TKA in the US. Spine Surgery in the US

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1 Preoperative Pain Neuroscience Education Adriaan Louw, PT, PhD California Physical Therapy Association Annual Upon completion of this educational session the participants will be able to: 1. Understand why a new bio-psycho-social approach was needed to address pain in orthopedic surgery 2. Understand the development and validation process of the preoperative neuroscience education program for orthopedic surgery 3. Be able to understand the content and delivery methods for the preoperative neuroscience educational program 4. Recognize why the preoperative neuroscience educational program produced superior results to the biomedical model utilized by US surgeons for orthopedic surgery 5. Apply the information from the educational session into clinical practice Disclaimers I publish books on pain and receive an honorarium for the sales. These are not being specifically promoted in the presentation. The intent is to share our research and not promote products. I teach for a seminar company offering continuing education for healthcare providers. The session is not designed to promote the attendance of the seminars. Spine Surgery in the US Very prevalent and ever-increasing Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA : the journal of the American Medical Association. Apr 7 21;33(13): Gray DT, Deyo RA, Kreuter W, et al. Population-based trends in volumes and rates of ambulatory lumbar spine surgery. Spine. Aug 1 26;31(17): ; discussion Deyo RA, Mirza SK. Trends and variations in the use of spine surgery. Clin Orthop Relat Res. Feb 26;443: Cherkin DC, Deyo RA, Loeser JD, Bush T, Waddell G. An international comparison of back surgery rates. Spine. Jun ;19(11): Spine Surgery in the US More than 2 million spine surgeries in the US annually inpatient and ambulatory Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA : the journal of the American Medical Association. Apr 7 21;33(13): Gray DT, Deyo RA, Kreuter W, et al. Population-based trends in volumes and rates of ambulatory lumbar spine surgery. Spine. Aug 1 26;31(17): ; discussion Deyo RA, Mirza SK. Trends and variations in the use of spine surgery. Clin Orthop Relat Res. Feb 26;443: Cherkin DC, Deyo RA, Loeser JD, Bush T, Waddell G. An international comparison of back surgery rates. Spine. Jun ;19(11): Knee OA and TKA in the US OA affects more than 26 million people in North America In 21 the United States Center for Disease Control reported that there were 719, TKA performed and it is expected these numbers will double by 22 Kopec JA, Rahman MM, Berthelot JM, et al. Descriptive epidemiology of osteoarthritis in British Columbia, Canada. The Journal of rheumatology. Feb 27;34(2): Williams S N, Wolford M L,Bercovitz A. (215). Hospitalization for Total Knee Replacement Among Inpatients Aged 45 and Over: United States, NCHS Cross M, Smith E, Hoy D, Nolte S, Ackerman I, Fransen M, Bridgett L, Williams S, Guillemin F, Hill C L, Laslett L L, Jones G, Cicuttini F, Osborne R, Vos T, Buchbinder R, Woolf A,March L 214 The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 21 study. Annals of the rheumatic diseases 73(7): without permission 1

2 1 in 4 patients experience persistent pain and disability after orthopedic surgery Riddle DL, Jiranek WA, Hayes CW. Use of a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States: a multicenter longitudinal cohort study. Arthritis Rheumatol. Aug 214;66(8): Johansson K, Nuutila L, Virtanen H, Katajisto J, Salantera S. Preoperative education for orthopaedic patients: systematic review. J Adv Nurs. Apr 25;5(2): Ostelo RW, de Vet HC, Waddell G, Kerckhoffs MR, Leffers P, van Tulder M. Rehabilitation following first-time lumbar disc surgery: a systematic review within the framework of the Cochrane collaboration. Spine. Feb 1 23;28(3): Baker P N, van der Meulen J H, Lewsey J, Gregg P J, National Joint Registry for E,Wales 27 The role of pain and function in determining patient satisfaction after total knee replacement. Data from the National Joint Registry for England and Wales. The Journal of bone and joint surgery. British volume 89(7): Kennedy D M, Hanna S E, Stratford P W, Wessel J,Gollish J D 26 Preoperative function and gender predict pattern of functional recovery after hip and knee arthroplasty. J Arthroplasty 21(4): Don t worry Problem #1: Referral to PT Patients are not readily referred to PT after lumbar surgery and TKA Postoperative rehabilitation will help persistent pain and disability after surgery McGregor AH, Burton AK, Sell P, Waddell G. The development of an evidence-based patient booklet for patients undergoing lumbar discectomy and un-instrumented decompression. Eur Spine J. Mar 27;16(3): Louw A, Butler DS, Diener I, Puentedura EJ. Preoperative education for lumbar radiculopathy: A Survey of US Spine Surgeons. International Journal of Spine Surgery. 212;6: Louw A, Puentedura EJ, Diener I. A descriptive study of the utilization of physical therapy for postoperative rehabilitation in patients undergoing surgery for lumbar radiculopathy. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. Nov 216;25(11): Artz N, Dixon S, Wylde V, Beswick A, Blom A, Gooberman-Hill R. Physiotherapy provision following discharge after total hip and total knee replacement: a survey of current practice at high-volume NHS hospitals in England and wales. Musculoskeletal care. Mar 213;11(1):31-38 Problem #2: Efficacy Limited efficacy for postoperative rehabilitation for spine surgery and rehabilitation may not be needed for TKA McGregor AH, Dore CJ, Morris TP, Morris S, Jamrozik K. ISSLS prize winner: Function After Spinal Treatment, Exercise, and Rehabilitation (FASTER): a factorial randomized trial to determine whether the functional outcome of spinal surgery can be improved. Spine. Oct 1 211;36(21): Ostelo RW, de Vet HC, Waddell G, Kerckhoffs MR, Leffers P, van Tulder M. Rehabilitation following first-time lumbar disc surgery: a systematic review within the framework of the Cochrane collaboration. Spine. Feb 1 23;28(3): Oosterhuis T, Costa LO, Maher CG, de Vet HC, van Tulder MW, Ostelo RW. Rehabilitation after lumbar disc surgery. The Cochrane database of systematic reviews. 214;3:CD37. Fransen M, Nairn L, Bridgett L, et al. Post-Acute Rehabilitation After Total Knee Replacement: A Multicenter Randomized Clinical Trial Comparing Long-Term Outcomes. Arthritis care & research. Feb ;69(2): Han AS, Nairn L, Harmer AR, et al. Early rehabilitation after total knee replacement surgery: a multicenter, noninferiority, randomized clinical trial comparing a home exercise program with usual outpatient care. Arthritis care & research. Feb 215;67(2): Health Quality O. Physiotherapy rehabilitation after total knee or hip replacement: an evidence-based analysis. Ontario health technology assessment series. 25;5(8):1-91. Problem #3: What should rehab consist of? Very little information available on: Content Frequency Timing Intensity Ostelo RW, de Vet HC, Waddell G, Kerckhoffs MR, Leffers P, van Tulder M. Rehabilitation following first-time lumbar disc surgery: a systematic review within the framework of the Cochrane collaboration. Spine. Feb 1 23;28(3): Oosterhuis T, Costa LO, Maher CG, de Vet HC, van Tulder MW, Ostelo RW. Rehabilitation after lumbar disc surgery. The Cochrane database of systematic reviews. 214;3:CD37. without permission 2

3 Problem #4: Who needs rehab? Being sent to PT after lumbar surgery was not correlated to higher levels of: Pain Disability Fear-Avoidance Pain Catastrophization Louw A, Puentedura EJ, Diener I. A descriptive study of the utilization of physical therapy for postoperative rehabilitation in patients undergoing surgery for lumbar radiculopathy. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. Nov 216;25(11): What about preoperative education? ORTHOPEDICS Hip replacement (Butler, Hurley et al. 1996; Daltroy, Morlino et al. 1998; McDonald, Hetrick et al. 24; McGregor, Rylands et al. 24; Johansson, Nuutila et al. 25) Knee replacement (Daltroy, Morlino et al. 1998; Mancuso, Sculco et al. 21; Beaupre, Lier et al. 24; McDonald, Hetrick et al. 24; Johansson, Nuutila et al. 25) Handful of studies have been conducted on preoperative education for patients undergoing spinal surgery (Douglas, Mann et al. 1998; Krupp, Spanehl et al. 2; LaMontagne, Hepworth et al. 23; Johansson, Nuutila et al. 25; Walters and Coad 26) Very little benefit Positive effect Preoperative anxiety levels Patient knowledge No changes to postoperative outcomes Pain ROM Function Length of hospital stay Louw A, Diener I, Butler DS, Puentedura EJ. Preoperative education addressing postoperative pain in total joint arthroplasty: review of content and educational delivery methods. Physiotherapy theory and practice. Apr 213;29(3): Johansson K, Nuutila L, Virtanen H, Katajisto J, Salantera S. Preoperative education for orthopaedic patients: systematic review. J Adv Nurs. Apr 25;5(2): McDonald S, Hetrick SE, Green S. Pre-operative educatiin for hip or knee replacement. Cochrane Database Syst Rev. 28(4). Why is it not helping? Procedural information Informed consent No postoperative benefit (Douglas, Mann et al. 1998; Krupp, Spanehl et al. 2; LaMontagne, Hepworth et al. 23; Johansson, Nuutila et al. 25; Walters and Coad 26 Only one study, utilizing pain education was able to reduce postoperative pain Louw A, Diener I, Butler DS, Puentedura EJ. Preoperative education addressing postoperative pain in total joint arthroplasty: review of content and educational delivery methods. Physiotherapy theory and practice. Apr 213;29(3): McDonald DD, Freeland M, Thomas G, Moore J. Testing a preoperative pain management intervention for elders. Res Nurs Health. Oct 21;24(5): Surgeons use biomedical models to teach patients prior to surgery Research into anatomy, biomechanical and pathoanatomy models Louw A, Butler DS, Diener I, Puentedura EJ. Preoperative education for lumbar radiculopathy: A Survey of US Spine Surgeons. International Journal of Spine Surgery. 212;6: % 7.% 6.% 5.% SURGICAL PROCEDURE 74.7% Not only have these models shown limited efficacy in decreasing pain and disability, but they may increase fear in patients, which in turn, may increase their pain 4.% 3.% 2.% 1.%.% 11.11% 8.64% Anatomy Biomechanics Instrumentation Greene DL, Appel AJ, Reinert SE, Palumbo MA. Lumbar disc herniation: evaluation of information on the internet. Spine (Phila Pa 1976). Apr 1 25;3(7): Morr S, Shanti N, Carrer A, Kubeck J, Gerling MC. Quality of information concerning cervical disc herniation on the Internet. Spine J. Apr 21;1(4): without permission 3

4 Add to this Surgeons underestimate their patients' desire for preoperative information Patients in general satisfied with the care given to them preoperatively but not with the content of the information regarding the impending surgery Patients expect to be pain-free after surgery Patients want more information on pain, especially following surgery Keulers BJ, Scheltinga MR, Houterman S, Van Der Wilt GJ, Spauwen PH. Surgeons underestimate their patients' desire for preoperative information. World J Surg. Jun 28;32(6): Ronnberg K, Lind B, Zoega B, Halldin K, Gellerstedt M, Brisby H. Patients' satisfaction with provided care/information and expectations on clinical outcome after lumbar disc herniation surgery. Spine. Jan 15 27;32(2): Toyone T, Tanaka T, Kato D, Kaneyama R, Otsuka M. Patients' expectations and satisfaction in lumbar spine surgery. Spine. Dec 1 25;3(23): Louw A, Louw Q, Crous LCC. Preoperative Education for Lumbar Surgery for Radiculopathy. South African Journal of Physiotherapy. July 29 29;65(2):3-8. The general population has an ambivalent and slightly negative view of spine surgery Landers, MR; Puentedura, EJ; Louw, A, et al A Population-Based Survey of Lumbar Surgery Beliefs in the United States. Orthopaedic Nursing; July/August (4) Central Sensitization Overall results suggest that, although peripheral mechanisms are involved in OA pain, hypersensitivity of the CNS plays a significant role in a subgroup of subjects within this population. High levels of pain catastrophization, anxiety and fear-avoidance prior to surgery is powerfully linked to poor outcomes Spine surgery TKA Baert, I. A., E. Lluch, et al. (215). "Does presurgical central modulation of pain influence outcome after total knee replacement? A systematic review." Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society. Theunissen M, Peters ML, Bruce J, Gramke HF, Marcus MA. Preoperative anxiety and catastrophizing: a systematic review and metaanalysis of the association with chronic postsurgical pain. Clin J Pain. Nov-Dec 212;28(9): Hirschmann MT, Testa E, Amsler F, Friederich NF. The unhappy total knee arthroplasty (TKA) patient: higher WOMAC and lower KSS in depressed patients prior and after TKA. Knee Surg Sports Traumatol Arthrosc. Oct 213;21(1): Lluch E, Torres R, Nijs J, Van Oosterwijck J. Evidence for central sensitization in patients with osteoarthritis pain: a systematic literature review. European journal of pain. Nov 214;18(1): In Summary Pain Disability High fear-avoidance Pain catastrophization Anxiety Biomedical explanation for pain Central sensitization Faulty cognitions and beliefs regarding surgery, recovery and pain Watson P, Kendall N. Assessing psychosocial yellow flags. In: Gifford LS, ed. Topical Issues in Pain 2. Falmouth: CNS Press; 2. Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychosocial yellow flags in acute low back pain: risk factors for long term disability and work loss. Wellington: Accident Rehabilitation & Compensation Insurance Corporation of New Zealand and the National Health Committee; Grotle M, Vollestad NK, Brox JI. Screening for yellow flags in first-time acute low back pain: reliability and validity of a Norwegian version of the Acute Low Back Pain Screening Questionnaire. The Clinical journal of pain. Jun 26;22(5): Moseley GL. Reconceptualising pain according to modern pain sciences. Physical Therapy Reviews. 27;12: Louw A. Treating the brain in chronic pain. In: C FdlP, J C, Dommerholt J, eds. Manual Therapy for Musculoskeletal Pain Syndromes. Vol 1. London: Churchill Livingston; 215 Low Threat High Threat without permission 4

5 Pain is 1% produced by the brain Pain is produced by the brain based on perception of threat Tell me more Woolf CJ. Central sensitization: uncovering the relation between pain and plasticity. Anesthesiology. Apr 27;16(4): Moseley GL. Reconceptualising pain acording to modern pain sciences. Physical Therapy Reviews. 27;12: How Dangerous is this? This is dangerous More information Facilitation Moseley, G.L., A pain neuromatrix approach to patients with chronic pain. Man Ther, 23. 8(3): p Melzack, R., Pain and the neuromatrix in the brain Journal of Dental Education, : p Facilitation Neuronal adaption Stop bugging me Woolf CJ. Central sensitization: uncovering the relation between pain and plasticity. Anesthesiology. Apr 27;16(4): Moseley GL. Reconceptualising pain acording to modern pain sciences. Physical Therapy Reviews. 27;12: How Dangerous is this? This not dangerous Less information Inhibition Neuronal adaption Inhibition So What? Pain is based on PERCEPTION of threat Pain is a perception We can influence perception Words Images Threat reappraisal Therapeutic alliance Ferreira PH, Ferreira ML, Maher CG, Refshauge KM, Latimer J, Adams RD. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Physical therapy. Apr 213;93(4): Example #1: Bad Disc Patients who underwent discectomy and shown their bad disc material recovered significantly better than those who were not shown their excised disc material Leg pain (91.5 vs. 8.4%; p<.5) Back pain (86.1 vs. 75.%; p<.5) Limb weakness (9.5 vs. 56.3%; p<.2) Paraesthesia (88 vs. 61.9%; p<.5) Reduced analgesic use (92.1 vs. 69.4%; p<.2) Tait MJ, Levy J, Nowell M, et al. Improved outcome after lumbar microdiscectomy in patients shown their excised disc fragments: a prospective, double blind, randomised, controlled trial. J Neurol Neurosurg Psychiatry. Sep 29;8(9): Example #2: Sham Surgery in Orthopedics Conclusion: Although care should be taken sham surgery has been shown to be just as effective as actual surgery in reducing pain and disability. Louw A, Diener I, Fernandez-de-Las-Penas C, Puentedura EJ. Sham Surgery in Orthopedics: A Systematic Review of the Literature. Pain Medicine. Jul without permission 5

6 Louw A, Diener I, Fernandez-de-Las-Penas C, Puentedura EJ. Sham Surgery in Orthopedics: A Systematic Review of the Literature. Pain Medicine. Jul Preoperative Pain Neuroscience Education Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. Apr 2;85(3): Gifford L. Aches and Pain. Cornwall: Wordpress; 214. Louw A, Puentedura EJ, Zimney K, Schmidt S. Know Pain, Know Gain? A Perspective on Pain Neuroscience Education in Physical Therapy. The Journal of orthopaedic and sports physical therapy. Mar 216;46(3): The ah-ha moment (for us) Evidence for PNE We started with Lumbar Surgery The results of this updated systematic review of PNE for MSK pain provides strong evidence for PNE improving pain ratings, pain knowledge, disability, pain catastrophization, fear-avoidance, attitudes and behaviors regarding pain, physical movement and healthcare utilization Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of physical medicine and rehabilitation. Dec 211;92(12): Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice. Jul 216;32(5): without permission 6

7 1. What do patients want? 2. What constitutes usual preoperative LS education? 3. What does the general population think about LS? 4. Is there any effective preoperative strategy that can be borrowed? 5. Is there any other effective strategy that can be borrowed from chronic LBP?? 6. What happens when a surgical brain understands more? 7. Can we develop a LS program using all of this information? 8. Does such a LS program produce superior results? 1. What do patients want? 76% of patients underwent surgery for pain Although 97% of patients thought their preoperative education was beneficial More than 1/3 felt they did not get enough education on pain 5% of patients surveyed at 4 weeks postoperative was afraid pain will get worse Louw A, Louw Q, Crous LCC. Preoperative Education for Lumbar Surgery for Radiculopathy. South African Journal of Physiotherapy. July 29 29;65(2): What constitutes usual preoperative LS education? 3. What does the general population think about LS? Louw A, Butler DS, Diener I, Puentedura EJ. Preoperative education for lumbar radiculopathy: A Survey of US Spine Surgeons. International Journal of Spine Surgery. 212;6: % 7.% 6.% SURGICAL PROCEDURE 74.7% Landers, MR; Puentedura, EJ; Louw, A, et al A Population-Based Survey of Lumbar Surgery Beliefs in the United States. Orthopaedic Nursing; July/August (4) 5.% 4.% 3.% 2.% 1.% 11.11% 8.64%.% Anatomy Biomechanics Instrumentation 4. Is there any effective preoperative strategy that can be borrowed? Preoperative Education for Orthopedics No changes to postoperative outcomes including pain, ROM, function or length of hospital stay. Only one study, utilizing pain education was able to reduce postoperative pain. Louw A, Diener I, Butler DS, Puentedura EJ. Preoperative education addressing postoperative pain in total joint arthroplasty: review of content and educational delivery methods. Physiotherapy theory and practice. Apr 213;29(3): McDonald DD, Freeland M, Thomas G, Moore J. Testing a preoperative pain management intervention for elders. Res Nurs Health. Oct 21;24(5): Is there any other effective strategy that can be borrowed from chronic LBP? The results of this updated systematic review of PNE for MSK pain provides strong evidence for PNE improving pain ratings, pain knowledge, disability, pain catastrophization, fear-avoidance, attitudes and behaviors regarding pain, physical movement and healthcare utilization Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of physical medicine and rehabilitation. Dec 211;92(12): Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice. Jul 216;32(5): without permission 7

8 5. Is there any other effective strategy that can be borrowed from chronic LBP? 5. Is there any other effective strategy that can be borrowed from chronic LBP? Louw A, Zimney K, O'Hotto C, Hilton S. The clinical application of teaching people about pain. Physiotherapy Theory and Practice. Jul 216;32(5): Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother. 22;48(4): Education to behavior change is like throwing wet spaghetti at a brick Fordyce WE, Fowler RS, Jr., Lehmann JF, Delateur BJ, Sand PL, Trieschmann RB. Operant conditioning in the treatment of chronic pain. Archives of physical medicine and rehabilitation. Sep 1973;54(9): What happens when a surgical brain understands more? Conclusion: Although care should be taken sham surgery has been shown to be just as effective as actual surgery in reducing pain and disability. Louw A, Diener I, Fernandez-de-Las-Penas C, Puentedura EJ. Sham Surgery in Orthopedics: A Systematic Review of the Literature. Pain Medicine. Jul Postop Patient Experience Surgeon current education General population s beliefs about surgery Expectations following surgery Louw A, Butler DS, Diener I, Puentedura EJ. Development of a preoperative neuroscience educational program for patients with lumbar radiculopathy. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. May 213;92(5): Provocative Language and Surgery Best evidence Neuroscience Education Sham Empowering the brain Viewing images prior to surgery What works in preop Ortho education Clinical Application Physical therapist One-on-one verbal format Pictures, examples, metaphors and drawings Conversational and personal approach rather than a lecture format. Standardized PNE program: checklist The educational sessions averaged 3 min. PNE book: Read at least one time before and one time after their surgery. Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1- year follow-up. Spine. Aug ;39(18): Louw A, Diener I, Landers MR, Zimney K, Puentedura EJ. Threeyear follow-up of a randomized controlled trial comparing preoperative neuroscience education for patients undergoing surgery for lumbar radiculopathy. Journal of spine surgery. Dec 216;2(4): * without permission 8

9 1. Decision to have surgery 2. The nervous system s physiology and pathways Normal electrical activity Take care of the issue Electrical activity waking up Nerves calm down 3. Peripheral nerve sensitization 4. Surgical experiences and environmental issues effects on nerve sensitivity 5. Calming the nervous system 6. Recovery after LS without permission 9

10 Does it work? 1. Who does it best? Analyzing 1 year RCT data: Unpublished data 1. Who does it best? 2. Comparative Language 3. Case Series Immediate effect 4. Brain changes fmri 5. RCT 1 year 6. PT after RCT 7. RCT 3 years Other therapists 5 years clinical experience NPQ > 9% PNET > 9% Go through tutorial of PNET Have taken 15h CEU on TNE Other PTs 2. Comparative Language: Some Background 2. Comparative Language Booklet A had almost 3 times as many provocative terms as Booklet B. Booklet A had an average of 67.2 provocative terms per reviewer compared to only 22.6 terms for Booklet B. Louw A, Diener I, Puentedura E. Comparison of Terminology in Patient Education Booklets for Lumbar Surgery. International Journal of Health Sciences. 214;2(3): Case Series Immediate effect 1 Patients scheduled for Surgery for L-Radiculopathy Ave. age 47 years; 7 females Ave. duration of leg pain 7 months Ave. time till surgery 9.5 days Ave. LBP rating 4.6/1 Ave. leg pain 4.1/1 Ave. Oswestry 4.8% Pain Catastrophization Scale: 25.4 FABQ-W: 15.8 FABQ-PA: 18.7 Pain knowledge: 12/19 SLR: 5 degrees Active trunk flexion 21cm Numerous poor beliefs about surgery Louw A, Diener I, Puentedura E. The short term effects of preoperative neuroscience education for lumbar radiculopathy: A case series. International Journal of Spine Surgery. 215;9(11). 3. Case Series Immediate effect Louw A, Diener I, Puentedura E. The short term effects of preoperative neuroscience education for lumbar radiculopathy: A case series. International Journal of Spine Surgery. 215;9(11). without permission 1

11 3. Case Series Immediate effect Louw A, Diener I, Puentedura E. The short term effects of preoperative neuroscience education for lumbar radiculopathy: A case series. International Journal of Spine Surgery. 215;9(11). 3. Case Series Immediate effect Physical Measurements (after education only): Passive SLR increased 9 degrees Active trunk flexion increased 5cm Louw A, Diener I, Puentedura E. The short term effects of preoperative neuroscience education for lumbar radiculopathy: A case series. International Journal of Spine Surgery. 215;9(11) Case Series Immediate effect Louw A, Diener I, Puentedura E. The short term effects of preoperative neuroscience education for lumbar radiculopathy: A case series. International Journal of Spine Surgery. 215;9(11). 4. Brain changes fmri Louw A, Puentedura EJ, Diener I, Peoples RR. Preoperative therapeutic neuroscience education for lumbar radiculopathy: a single-case fmri report. Physiotherapy Theory and Practice. Oct 215;31(7): Before TNE After TNE I feel prepared and ready for surgery I am afraid of the upcoming surgery I know what to expect after back surgery Back pain after surgery is to be expected Leg pain after surgery is to be expected I can control the Back surgery will fix amount of my pain postoperative pain * 4. Brain changes fmri Louw A, Puentedura EJ, Diener I, Peoples RR. Preoperative therapeutic neuroscience education for lumbar radiculopathy: a single-case fmri report. Physiotherapy Theory and Practice. Oct 215;31(7): REST PERIOD 4. Brain changes fmri Immediately following PNE straight leg raise increased by 7 and forward flexion by 8 cm Louw A, Puentedura EJ, Diener I, Peoples RR. Preoperative therapeutic neuroscience education for lumbar radiculopathy: a single-case fmri report. Physiotherapy Theory and Practice. Oct 215;31(7): without permission 11

12 Louw A, Puentedura EJ, Diener I, Peoples RR. Preoperative therapeutic neuroscience education for lumbar radiculopathy: a sing le-case fmri report. Physiotherapy Theory and Practice. Oct 215;31(7): Resting Scan 5. RCT - 1 Year Painful Task Same Painful Task after 2 minute PNE session Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1- year follow-up. Spine. Aug ;39(18): RCT - 1 Year No statistical significance: Back Pain Leg Pain Catastrophization Fear Avoidance Pain Knowledge Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up. Spine. Aug ;39(18): RCT - 1 Year Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up. Spine. Aug ;39(18): Surgical Experience Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up. Spine. Aug ;39(18): RCT - 1 Year 45% less on medical tests and treatments 5. RCT - 1 Year Louw A, Puentedura EJ, Zimney K, Schmidt S. Know Pain, Know Gain? A Perspective on Pain Neuroscience Education in Physical Therapy. J Orthop Sports Phys Ther. Mar 216;46(3): without permission 12

13 PT After LS Back pain Leg pain Disability Fear-avoidance, Pain catastrophization Pain knowledge Various LS beliefs and experiences Louw A, Puentedura EJ, Diener I. A descriptive study of the utilization of physical therapy for postoperative rehabilitation in patients undergoing surgery for lumbar radiculopathy. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. Nov 216;25(11): Before Surgery 1 Month postop 3 Months postop 6 Months postop 12 Months postop None of these predicted who attended PT after LS for radiculopathy 7. 3-year Outcomes Experimental Louw A, Diener I, Landers MR, Zimney K, Puentedura EJ. Three-year follow-up of a randomized controlled trial comparing preoperative neuroscience education for patients undergoing surgery for lumbar radiculopathy. Journal of spine surgery. Dec 216;2(4): Control 3 years - PPA 3 years - ITT 37% healthcare savings at 3 years Lumbar Surgery What we re working on right now 122 patients undergoing TKA PNE Preoperative Hospital Education Preoperative Hospital Education PNE: 3 minute group session 6 Months Pain Function Pain Medication use Blood pressure and Heart Rate Length of Hospital stay Knee ROM Satisfaction with surgery Healthcare utilization Immediate Effects of Preoperative Neuroscience Education for Patients Undergoing Total Knee Arthroplasty: a case series Louw, Zimney, Peuntedura and Reed accepted for publication 1 Immediate Effects of Preoperative Neuroscience Education for Patients Undergoing Total Knee Arthroplasty: a case series Louw, Zimney, Peuntedura and Reed accepted for publication Before PNE After PNE I feel prepared and ready I am afraid of the for the knee surgery upcoming knee surgery I know what to expect Knee pain after surgery is I can control the amount The knee surgery will fix after the knee surgery to be expected of postoperative pain I my pain experience Pre PNE Post PNE 2 TKA Knee Nonoperative Knee Dominant Hand without permission 13

14 Louw, Reed, Zimney, Puentedura, Grimm and Landers submitted for publication 122 patients undergoing TKA RCT: Preoperative PNE for TKA PNE Preoperative Hospital Education Preoperative Hospital Education 6 5 Pain 6 5 Disability Months Pain Function Pain Medication use Blood pressure and Heart Rate Length of Hospital stay Knee ROM Satisfaction with surgery Healthcare utilization Pre 1 Month 3 Months 6 Months Pre 1 Month 3 Months 6 Months Experimental Control Experimental Control Louw, Reed, Zimney, Puentedura, Grimm and Landers submitted for publication RCT: Preoperative PNE for TKA RCT: Preoperative PNE for TKA Kinesiophobia Pre 1 Month 3 Months 6 Months Experimental Control Pain Catastrophization Pre 1 Month 3 Months 6 Months Experimental Control Patient Experience * * * Glad Fully Prep Prep Well Do Again Met Expectation Experimental Control Louw, Reed, Zimney, Puentedura, Grimm and Landers submitted for publication Louw, Reed, Zimney, Puentedura, Grimm and Landers submitted for publication Next Preoperative PNE for Shoulder Surgery 48% Louw, Langerwerf and Cox Study in progress Louw, Langerwerf and Cox Study in progress without permission 14

15 Patient Every Joint Has A Brain Louis Gifford Gifford L. Aches and Pain. Cornwall: Wordpress; 214. Patients want to know 1. What is wrong with me? 2. How long will it take? 3. What can I (the patient) do for it? 4. What can you (the clinician) do for it? Thank you & acknowledgements Adriaan@ispinstitute.com Colleen, Hailey and Samuel Louw Ina Diener Louis Gifford Cesar Fernandez John Childs Tim Flynn Josh Cleland Lorimer Moseley David Butler Merrill Landers Steve Schmidt ISPI staff and faculty without permission 15