Teaching People About Pain Therapeutic Neuroscience Education

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1 Teaching People About Pain Therapeutic Neuroscience Education Jessie Podolak, PT, DPT, Therapeutic Pain Specialist >100 Million Americans have some form of persistent pain Institute of Medicine 2012: Relieving Pain in America US Pain Epidemic We re number 1 expressed permission from ISPI 1

2 Chronic pain has doubled in the last years! 1. Bruehl S, Chung OY. How common is complex regional pain syndrome-type I? Pain. May 2007;129(1-2): Medicine) IIo. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research, The National Academies Press Raftery MN, Sarma K, Murphy AW, De la Harpe D, Normand C, McGuire BE. Chronic pain in the Republic of Ireland--community prevalence, psychosocial profile and predictors of pain-related disability: results from the Prevalence, Impact and Cost of Chronic Pain (PRIME) study, part 1. Pain. May 2011;152(5): Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internetbased survey. The journal of pain : official journal of the American Pain Society. Nov 2010;11(11): van Hecke O, Torrance N, Smith BH. Chronic pain epidemiology and its clinical relevance. British journal of anaesthesia. Jul 2013;111(1): Hooker AB, van Moorst BR, van Haarst EP, van Ootegehem NA, van Dijken DK, Heres MH. Chronic pelvic pain: evaluation of the epidemiology, baseline demographics, and clinical variables via a prospective and multidisciplinary approach. Clin Exp Obstet Gynecol. 2013;40(4): Parthan A, Evans CJ, Le K. Chronic low back pain: epidemiology, economic burden and patient-reported outcomes in the USA. Expert Rev Pharmacoecon Outcomes Res. Jun 2006;6(3): Sjogren P, Ekholm O, Peuckmann V, Gronbaek M. Epidemiology of chronic pain in Denmark: an update. European journal of pain. Mar 2009;13(3): Azevedo LF, Costa-Pereira A, Mendonca L, Dias CC, Castro-Lopes JM. Epidemiology of chronic pain: a population-based nationwide study on its prevalence, characteristics and associated disability in Portugal. The journal of pain : official journal of the American Pain Society. Aug 2012;13(8): Bekkering GE, Bala MM, Reid K, et al. Epidemiology of chronic pain and its treatment in The Netherlands. Neth J Med. Mar 2011;69(3): Jakobsson U. The epidemiology of chronic pain in a general population: results of a survey in southern Sweden. Scandinavian journal of rheumatology. 2010;39(5): Reitsma M, Tranmer JE, Buchanan DM, VanDenKerkhof EG. The epidemiology of chronic pain in Canadian men and women between 1994 and 2007: longitudinal results of the National Population Health Survey. Pain research & management : the journal of the Canadian Pain Society = journal de la societe canadienne pour le traitement de la douleur. May-Jun 2012;17(3): Goldberg DS, McGee SJ. Pain as a global public health priority. BMC Public Health. 2011;11: Cimmino MA, Ferrone C, Cutolo M. Epidemiology of chronic musculoskeletal pain. Best Pract Res Clin Rheumatol. Apr 2011;25(2): What is Pain? Louw A, Butler DS. Chronic Pain. In: S.B. B, Manske R, eds. Clinical Orthopaedic Rehabilitation. 3rd Edition ed. Philadelphia, PA: Elsevier; Wade, D., Why physical medicine, physical disability and physical rehabilitation? We should abandon Cartesian dualism. Clin Rehab, : p What s wrong with Rene? Assumption: there is a direct link between the amount of tissue damage and the level of pain experienced. (Patients truly believe this) All pain is caused by injury and increased pain means more damage Pain is either physical or psychological (mental versus physical) In chronic pain tissues are not healing and damage is ongoing Nociception and pain is synonymous Louw A, Butler DS. Chronic Pain. In: S.B. B, Manske R, eds. Clinical Orthopaedic Rehabilitation. 3rd Edition ed. Philadelphia, PA: Elsevier; Wade, D., Why physical medicine, physical disability and physical rehabilitation? We should abandon Cartesian dualism. Clin Rehab, : p The REAL issue Haldeman S. Presidential address, North American Spine Society: failure of the pathology model to predict back pain. Spine. 1990;15(7): expressed permission from ISPI 2

3 This happens This also happens (thank goodness) Iwamoto J, Takeda T, Wakano K. Returning athletes with severe low back pain and spondylolysis to original sporting activities with conservative treatment. Scand J Med Sci Sports. Dec 2004;14(6): We need a more comprehensive explanation Physical Therapy Our knowledge of pain has increased considerably Louw A, Puentedura E. Therapeutic Neuroscience Education: Teaching patients about pain. Minneapolis, MN: OPTP; expressed permission from ISPI 3

4 Gifford LS. Pain, the tissues and the nervous system. Physiotherapy. 1998;84: Tissues OUTPUTS: Pain Action programs Stress regulation Environment INPUTS: Tissue sampling Environment PROCESSING via BODY-SELF NEUROMATRIX: Sensory Cognitive (experience, attention, etc.) Conceptual model from Butler Evolutionary Biology Onion skins Representation Pain mechanisms Bio-psycho-social approach Beliefs/fears/threats Louw A, Butler DS. Chronic Pain. In: S.B. B, Manske R, eds. Clinical Orthopaedic Rehabilitation. 3rd Edition ed. Philadelphia, PA: Elsevier; Biomechanics Pathoanatomy Anatomy Image from Butler D, Moseley G. Explain Pain. Adelaide: Noigroup; Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85: expressed permission from ISPI 4

5 Pull back Do less Increased fear Could also be emotional overload Choice made Importance of early education? The dichotomy Nijs J, Roussel N, Paul van Wilgen C, Koke A, Smeets R. Thinking beyond muscles and joints: therapists' and patients' attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Man Ther. Apr 2013;18(2): Irrational thoughts Limited knowledge Knowledge Threatening and provocative words; Medical tests; Various opinions; Internet information; Experiences 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; Lumbar Discs 40% of people with no back pain has a bulging disc Disc bulges absorb 1. Yukawa Y, Kato F, Matsubara Y, Kajino G, Nakamura S, Nitta H. Serial magnetic resonance imaging follow-up study of lumbar disc herniation conservatively treated for average 30 months: relation between reduction of herniation and degeneration of disc. J Spinal Disord. Jun 1996;9(3): Masui T, Yukawa Y, Nakamura S, et al. Natural history of patients with lumbar disc herniation observed by magnetic resonance imaging for minimum 7 years. J Spinal Disord Tech. Apr 2005;18(2): Mochida K, Komori H, Okawa A, Muneta T, Haro H, Shinomiya K. Regression of cervical disc herniation observed on magnetic resonance images. Spine. May ;23(9): ; discussion Matsubara Y, Kato F, Mimatsu K, Kajino G, Nakamura S, Nitta H. Serial changes on MRI in lumbar disc herniations treated conservatively. Neuroradiology. Jul 1995;37(5): Komori H, Okawa A, Haro H, Muneta T, Yamamoto H, Shinomiya K. Contrast-enhanced magnetic resonance imaging in conservative management of lumbar disc herniation. Spine. Jan ;23(1): Rotator Cuff 1/3 people over age 30 has abnormal findings on MRI 2/3 people over age 70 has abnormal findings on MRI After successful rotator cuff surgery 90% of people have abnormal findings on MRI Spielmann AL, Forster BB, Kokan P, Hawkins RH, Janzen DL. Shoulder after rotator cuff repair: MR imaging findings in asymptomatic individuals--initial experience. Radiology. Dec 1999;213(3): Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. The Journal of bone and joint surgery. American volume. Jan 1995;77(1): Reilly P, Macleod I, Macfarlane R, Windley J, Emery RJ. Dead men and radiologists don't lie: a review of cadaveric and radiological studies of rotator cuff tear prevalence. Ann R Coll Surg Engl. Mar 2006;88(2): Milgrom C, Schaffler M, Gilbert S, van Holsbeeck M. Rotatorcuff changes in asymptomatic adults. The effect of age, hand dominance and gender. J Bone Joint Surg Br. Mar 1995;77(2): expressed permission from ISPI 5

6 Arthritis and LBP Injury, pain and disability Taylor JR, Twomey LT. Age changes in lumbar zygapophyseal joints. Observations on structure and function. Spine (Phila Pa 1976). Sep 1986;11(7): Twomey L. Clinical Anatomy of the Lumbar Spine and Sacrum. Third ed. New York: Churchill Livingstone; Pain is 100% produced by the brain Pain is a multiple system output, activated by an individual s specific pain neural signature. The neural signature is activated whenever the brain perceives a Would this hurt? Moseley, G.L., A pain neuromatrix approach to patients with chronic pain. Man Ther, (3): p Melzack, R., Pain and the neuromatrix in the brain Journal of Dental Education, : p Louw A. Why Do I Hurt? A Neuroscience Approach to Pain. Minneapolis: OPTP; expressed permission from ISPI 6

7 What if? Pain is a decision by the brain based on perception of THREAT Louw A. Why Do I Hurt? A Neuroscience Approach to Pain. Minneapolis: OPTP; Louw A. Why Do I Hurt? A Neuroscience Approach to Pain. Minneapolis: OPTP; What is considered a THREAT? Degenerative Disc Disease Degenerative Joint Disease Herniated Disk Bulging Disk Black Disk Torn Ripped Slipped Arthritic Collapsed Louw A. Why Do I Hurt? A Neuroscience Approach to Pain. Minneapolis: OPTP; expressed permission from ISPI 7

8 The brain under threat: the brain on pain A TYPICAL PAIN NEUROTAG 1. PREMOTOR/ MOTOR CORTEX 1 5 organize and prepare movements 2 2. CINGULATE CORTEX concentration, focusing 3 3. PREFRONTAL CORTEX 6 problem solving, memory AMYGDALA fear, fear conditioning, addiction 7 5. SENSORY CORTEX sensory discrimination 9 6. HYPOTHALAMUS/ THALAMUS stress responses, autonomic regulation, motivation 7. CEREBELLUM movement and cognition 8. HIPPOCAMPUS memory, spacial recognition, fear conditioning 9. SPINAL CORD gating from the periphery Butler & Moseley 2003 Options for altering threat Traditional: Bottom up... Gifford L. Aches and Pain. Cornwall: Wordpress; Gifford LS. Pain, the tissues and the nervous system. Physiotherapy. 1998;84: expressed permission from ISPI 8

9 Traditional Education Greene DL, Appel AJ, Reinert SE, Palumbo MA. Lumbar disc herniation: evaluation of information on the internet. Spine (Phila Pa 1976). Apr ;30(7): Traditional Education Models Louw A, Butler DS. Chronic Pain. In: S.B. B, Manske R, eds. Clinical Orthopaedic Rehabilitation. 3rd Edition ed. Philadelphia, PA: Elsevier; Anatomy 2. Biomechanics 3. Pathoanatomy These models are very prevalent in PT Prevailing biomedical models focus on tissues and tissue injury. Orthopedic-based professions commonly use anatomy and patho-anatomy based models to explain pain to their patients. Louw A, Diener I, Puentedura E. Comparison of Terminology in Patient Education Booklets for Lumbar Surgery. International Journal of Health Sciences. 2014;2(3): Henrotin YE, Cedraschi C, Duplan B, Bazin T, Duquesnoy B. Information and low back pain management: a systematic review. Spine. May ;31(11):E Houben RM, Ostelo RW, Vlaeyen JW, Wolters PM, Peters M, Stomp-van den Berg SG. Health care providers' orientations towards common low back pain predict perceived harmfulness of physical activities and recommendations regarding return to normal activity. Eur J Pain. Apr 2005;9(2): expressed permission from ISPI 9

10 Research into anatomy, biomechanical and pathoanatomy models 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. Greene DL, Appel AJ, Reinert SE, Palumbo MA. Lumbar disc herniation: evaluation of information on the internet. Spine (Phila Pa 1976). Apr ;30(7): Morr S, Shanti N, Carrer A, Kubeck J, Gerling MC. Quality of information concerning cervical disc herniation on the Internet. Spine J. Apr 2010;10(4): What about a top-down approach? 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 2015;31(7): expressed permission from ISPI 10

11 Teaching People About Pain 1998 Since then Gifford L, Muncey H. Explaining Pain to Patients. Paper presented at: International Association on the Study of Pain1999; Vienna, Austria. Louw A, Puentedura EJ. Therapeutic Neuroscience Education. Vol 1. Minneapolis, MN: OPTP; First RCT Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother. 2002;48(4): year-old female 4.5 years of pain Started as LBP, then spread to her buttocks and now into both legs Pain would flare up with stress at work First child 2.5 years ago horrible labor, delivery and pain Now constant LBP Not able to return to work Now severe spasms in both legs CT, MRI and X-Ray WNL Meds: High doses of pain killers and narcotics Moseley GL. Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fmri evaluation of a single patient with chronic low back pain. Aust J Physiother. 2005;51(1): expressed permission from ISPI 11

12 Segmental Spinal Stabilization Exercises: 1 week practice 5 minutes each waking hour 1 to 1 pain physiology education Moseley GL. Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fmri evaluation of a single patient with chronic low back pain. Aust J Physiother. 2005;51(1): Moseley GL. Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fmri evaluation of a single patient with chronic low back pain. Aust J Physiother. 2005;51(1): Evidence Updated Systematic Review The Efficacy of Therapeutic Neuroscience Education on Musculoskeletal Pain An Updated Systematic Review of the Literature Adriaan Louw, PT, PhD Kory Zimney, PT, DPT Louie Puentedura, PT, PhD Ina Diener, PT, PhD The results of this updated systematic review of TNE for MSK pain provides strong evidence for TNE 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 2011;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. Physiother Theory and Pract. July 2016;32(5): expressed permission from ISPI 12

13 TNE: It works for Chronic Pain The Efficacy of Therapeutic Neuroscience Education on Musculoskeletal Pain An Updated Systematic Review of the Literature The results of this updated systematic review of TNE for MSK pain provides strong evidence for TNE improving pain ratings pain knowledge Disability pain catastrophization Adriaan Louw, PT, PhD fear-avoidance Kory Zimney, PT, DPT attitudes and behaviors regarding pain Louie Puentedura, PT, PhD physical movement Ina Diener, PT, PhD healthcare utilization TNE: Who needs it? Central sensitization Pain Catastrophization Fear-Avoidance Disability Pain 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 2011;92(12): Meeus M, Nijs J, Van Oosterwijck J, Van Alsenoy V, Truijen S. Pain Physiology Education Improves Pain Beliefs in Patients With Chronic Fatigue Syndrome Compared With Pacing and Self-Management Education: A Double-Blind Randomized Controlled Trial. Arch Phys Med Rehabil. Aug 2010;91(8): Nijs J, Paul van Wilgen C, Van Oosterwijck J, van Ittersum M, Meeus M. How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: practice guidelines. Manual therapy. Oct 2011;16(5): Moseley GL, Hodges PW, Nicholas MK. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clinical Journal of Pain. 2004;20: Nijs J, Paul van Wilgen C, Van Oosterwijck J, van Ittersum M, Meeus M. How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: Practice guidelines. Manual therapy. Oct 2011;16(5): Preoperative Neuroscience Education: Single fmri case Louw, Diener, Peoples and Puentedura Physiother Theory Pract. 2015;31(7): TNE: Improves Patient Satisfaction 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 Resting fmri scan Painful spine movements prior to TNE fmri scan Same spine movements after TNE fmri scan expressed permission from ISPI 13

14 TNE: Improves Healthcare Cost Louw, Puentedura, Landers, Diener and Zimney 2015 submitted for publication 1 Year Cost Difference (45%) 3 Year Cost Difference (60%) Movement improves after TNE-Only p = Year 3 Years 9452 EG UCG 1 year postop $ 1.2 Billion savings 3 years postop $ 2.1 Billion savings Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain. Sep-Oct 2004;20(5): But TNE needs movement to decrease pain TNE: Who does it? To date, all TNE sessions delivered by. Physical therapists 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 2011;92(12): expressed permission from ISPI 14

15 The Late Patrick Wall, MD, PhD PT is the ideal profession to take on pain Biology Movement Time Cheap Lots of foot soldiers Exercise Hands-on Phycology Pain science Teams Don t forget about your PTA s Many of the pain treatments can (should) be done by a PTA Louw A, Cox T. Pain. In: Manske R, ed. Fundamental Orthopedic Management for the PTA. 4th ed: Elsevier; TNE: The Ice-burg Effect Personal communication between Adriaan Louw and Lorimer Moseley TNE: What Does it Look Like? CONTENT: Neurophysiology of pain No reference to anatomical or patho-anatomical models No discussion of emotional or behavioral aspects to pain Nociception and nociceptive pathways Neurons Synapses Action potential Spinal inhibition and facilitation Peripheral sensitization Central sensitization Plasticity of the nervous system 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 2011;92(12): Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother. 2002;48(4): expressed permission from ISPI 15

16 Education Delivery Methods Professionals Physical therapists Duration and frequency minutes 1-2x/week Educational format One-on-one verbal communication Two studies utilized group sessions. Educational tools Prepared pictures Metaphors Examples Hand drawings Workbook Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother. 2002;48(4): Meeus M, Nijs J, Van Oosterwijck J, Van Alsenoy V, Truijen S. Pain Physiology Education Improves Pain Beliefs in Patients With Chronic Fatigue Syndrome Compared With Pacing and Self-Management Education: A Double-Blind Randomized Controlled Trial. Arch Phys Med Rehabil. Aug 2010;91(8): Van Oosterwijck J, Nijs J, Meeus M, et al. Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: A pilot study. J Rehabil Res Dev. 2011;48(1):EPub ahead of print Adjunct treatment Manual therapy Soft tissue treatment/massage Neural tissue mobilisation Spinal stabilisation exercises Home exercises None (neuroscience education only) Circuit training Aerobic exercise 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 2011;92(12): Ryan CG, Gray HG, Newton M, Granat MH. Pain biology education and exercise classes compared to pain biology education alone for individuals with chronic low back pain: a pilot randomised controlled trial. Man Ther. Aug 2010;15(4): The Rules when considering TNE Screen accordingly Use outcome measures Thorough interview Thorough low tech examination Compassion and empathy Louw A, Puentedura EL, Mintken P. Use of an abbreviated neuroscience education approach in the treatment of chronic low back pain: a case report. Physiotherapy theory and practice. Jan 2012;28(1): Nijs J, Paul van Wilgen C, Van Oosterwijck J, van Ittersum M, Meeus M. How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: practice guidelines. Manual therapy. Oct 2011;16(5): Zimney K, Louw A, Puentedura EJ. Use of Therapeutic Neuroscience Education to address psychosocial factors associated with acute low back pain: a case report. Physiotherapy theory and practice. Apr 2014;30(3): Interview Traditional What brings you to therapy? Where is your pain? Describe your pain? Is it constant or intermittent? What makes it better? What makes it worse? - Not adequate expressed permission from ISPI 16

17 Interview peeling layers What do you think is going on with your [fill in area they are seeking help for]? What do you think should be done for your [fill in area they are seeking help for]? Why do you think you still hurt? What would it take for you to get better? Where do you see yourself in 3 years in regards to [fill in area they are seeking help for]? Interview peeling layers What gives you hope? What is your expectation of PT? If I could flip a switch and remove all your pain, what things you have given up on would you do again? Are you angry at anyone about your [fill in area they are seeking help for]? Tell me about it. Has anyone made you feel like you re just making it up or it s in your head? Tell me about it. Listening is therapy Physical Examination THOROUGH More low tech than high tech Large, functional, physiological Neuro Neurodynamic tests Nerve palpation Pressure algometry TPD Nijs J, Van Houdenhove B, Oostendorp RA. Recognition of central sensitization in patients with musculoskeletal pain: Application of pain neurophysiology in manual therapy practice. Man Ther. Apr 2010;15(2): Linton SJ. The socioeconomic impact of chronic back pain: is anyone benefiting? Pain. Apr 1998;75(2-3): Starting the pain talk Has anyone explained to you why you hurt? Would you like to know why your pain is not getting better? Before we start some of the physical treatment, I d like to explain to you a little more about your pain? expressed permission from ISPI 17

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23 Something physical Exercise Movement Breathing Relaxation Etc. In the clinic.after TNE Homework Think, read, questions Walking program 2-3 basic exercises Goals Teach people about pain Exercise Modalities Manual therapy Relaxation/Meditation Breathing Sleep hygiene Safe, healing environment Coping skills Pacing and graded exposure Goal setting More. End-Result Clinical Pearl: is Therapy EVERYTHING we do determines the outcome. Listening.is therapy Education.is therapy Compassion is therapy Movement.is therapy A good receptionist..is therapy Time is therapy Trust.is therapy expressed permission from ISPI 23

24 We DO NOT manage pain! Pain management Pain program I ll finish with the MOST IMPORTANT slide of the day Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother. 2002;48(4): Gifford L. Aches and Pain. Cornwall: Wordpress; Louis Gifford 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? 5. (How much will it cost?) added by Adriaan Louis Gifford expressed permission from ISPI 24