Pain Neuroscience Education (PNE)
There is a growing body of scientific evidence that supports recovery from chronic pain using a patient education program. This program is called ‘pain neuroscience education’ or PNE. It has been pioneered by the physical therapists Louis Gifford from the UK, and Lorimer Moseley and David Butler from Adelaide, Australia. It is championed here in the US by the PT, Adriaan Louw.
Louis Gifford died an untimely death early in 2014, but before he died he published many scientific papers about the vagaries of pain, and how it doesn’t play by the rules. He lectured extensively on the clinical biology of pain, the nerve root and treatment through graded exposure. Although I didn’t meet and study with Louis, I have devoured his three book series titled ‘Aches and Pains’. They are wonderful exposés that question western medicine’s sometimes futile treatment methods for chronic pain.
Lorimer Moseley and David Butler are both highly entertaining and erudite Australians who promote the NOI group around the world. The NOI group website is www.niogroup.com Their philosophy is to “create and provide evidence-based multimedia resources and courses for the treatment of pain”. Lorimer is also the web master of a web site for clinicians www.bodyinmind.org David is the author of the seminal self-help text ‘Explain Pain’.
Adriaan Louw, originally from South Africa, but now residing in Iowa, is the author of the deep and meaningful ‘Therapeutic Neuroscience Education: Teaching Patients About Pain’ for therapists, and the cute and inexpensive spiral bound note book “Why do I hurt?’. This is for patients.
Lorimer believes that pain is a multi-system output or neurosignature from the brain. Pain is constructed whenever the brain concludes that the body tissues are in threat and action is required. This danger can be real, or believed to be real and can change over time. This bioplasticity is hard to break into (but not impossible) if it becomes entrenched.
Acute pain has meaning. Stub your toe – it hurts. Chronic pain often has no meaning. What useful purpose does a migraine serve? Does it tell you that you have a disease, a trauma, a lesion? People can have a metal spike through their skull and into their brain and feel no pain. What’s that all about? Pain often pairs up with a poor body-image, anxiety, insomnia and depression. It can also be a reminder of past trauma.
The perception of pain is normal. Without it we would lead miserable lives. On the other hand, living with longstanding pain is not normal. In this case, something has changed in the body. Some call this event neuroplasticity. I prefer bioplasticity.
We call unpleasant signaling of information ‘nociception’. Signals travel from the periphery to the spinal cord to be processed. These signals can be trigger point in origin. The spinal cord has the ability to ‘shut the gate’ to pain using powerful chemicals. Think of survival mode, or an athlete’s ability to ‘run through the wall’. (The gate can also shut if you rub the elbow you just banged. A more pleasant sensation.)
If the gate opens to pain, the spinal cord sends this nociception up to the thalamus which is like a relay station. The thalamus sends nociception to many parts of the brain. We call this the neuromatrix. Signals are then processed, made sense of, and an appropriate response should be sent to the appropriate part of the body. This is where we can now use the word ‘pain’ instead of nociception. Pain is processed by the brain. After, or even during, the acute phase of pain the brain can generate painkilling chemicals to inhibit signals coming up the spinal cord. In fact these enkephalins and endorphins are the most powerful analgesic drugs known to man. Nociception is dulled and even inhibited such as to not register. All good.
But, after being bombarded over a long period of time the brain can get this inhibitory stuff all wrong. In fact it can make too much pain, and send it to other unaffected locations. Spots miles away from the original injury. We call this facilitation of pain. In these chronic states the brain undergoes both structural and functional changes. The thresholds of reception of nociceptive chemicals at skin and muscle level have gone down. The excitability of neurons in the spinal cord has gone up. Things are looking grim. Words like fibromyalgia and chronic regional pain syndrome are handed out. What to do?
If you have read everything to this point, you’re already doing well. Knowledge is power. Part of your treatment will have me flesh-out the simplistic neurobiology described above.
I have been privileged to study both David Butler and Adriaan Louw. They have opened my eyes to the helpfulness of giving pain sufferers an understanding of what led to their condition. There are decent interventions to give hope of recovery. I’ve used them successfully on many patients. My own NMT method employs scientific explanations, metaphors and stories of success (along with manual therapy) to help a sufferer give meaning to their pain. At the same time people will reconnect with their body. Safe, slow paced movement patterns lead to actual exercise, that slowly but surely eliminates pain.
- Deep listening, after asking relevant questions.
- Correlation does not always equal causation.
- Running through the options.
- A variety of pain questionnaires.
- Palpation of the tissue where the pain is, and also distant to it.
- Measurement of subjective pain using an algometer and pressure-pain thresholds.
- Measurements, to monitor subsequent improvements.
- Bony landmarks and movement ranges and patterns.
- Evaluate all aspects of your daily activity; nutrition, sleep, stress, ergonomics, general health.
- Formulate a plan.
- Learn about the anatomy and physiology of pain, and the course it took with you.
- Start your return to activity with something achievable.
- Make the progression gradual, interesting and fun.
- Get reconnect to your body and start to feel safe and confident in it.
- Bring in an aerobic exercise component.
- Make sure that sleep is optimized.
- Get some decent bodywork, like neuromuscular therapy.
- Lastly, make a plan to do something outrageous.
There is hope for people in chronic pain. Knowing how pain is generated, and then how it sometimes goes awry, before it goes away is part of the rehabilitation process.
Below is a list of great reads on the subject. One of my favorites is ‘The Culture of Pain’ by David Morris. It is over 25 years old and yet still contemporary. Very readable too.
For the patient, easy to read, cheap
For the patient, deeper, more information
For the patient
David Nelson (U of Illinois,Champagne-Urbana)
Written by a famous pain researcher.
People love this book
Patient Self Help
Comes with a CD for self healing
For the Therapists
Sharon Sauer & Mary Biancalana
Devin Starlanyl & Mary Ellen Copeland
Good Read for the patient
For patient & therapists
Therapists and patients
Therapists and patients