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Pain science and patient education

This is an excerpt from Therapeutic Interventions for Musculoskeletal Conditions With HKPropel Online Video by Craig R. Denegar,Grant Norte,Neal Glaviano.

The origins of pathological pain are multifactorial. The network that transmits pain to prevent damage and protect healing tissues can be altered in the periphery, dorsal horn, and brain in a manner that fosters hyperalgesia and allodynia. To reiterate, at this time, there are no simple solutions that fully alleviate persisting pain and resultant functional and participation limitations experienced by patients. Interventions used to manage nociceptive pain often fail to alleviate and may exacerbate pathological pain.

The understanding of pathological pain has grown since the late 1990s, but it is still a foreign concept to many. Students entering health professions programs commonly understand pain as an indicator of injury or illness based on their lived experiences. Providers’ views are shaped by their experiences and training. The extent to which older understandings have been reshaped by continuing education and self-directed learning varies. From this foundation, providers grapple with the challenge of explaining pain and helping patients understand why the pain they are experiencing has not gone away.

Pain neuroscience education (PNE) is a formal and planned process to help patients understand why pain persists. Louw and colleagues suggested that the general aims of PNE are to decrease the threat value of pain, reduce catastrophic thinking, and facilitate exploration of active coping strategies.²² Moseley and Butler used the term explaining pain (EP) to refer to a range of educational interventions that aim to provide patients with a foundation in the mechanisms of persisting pain.²³ Although they do not prescribe a specific educational program or approach, they differentiated EP from cognitive behavior therapy and identified aspects of their approach providers can draw on.

• Providers should not suggest that there is not a known cause or cure for central sensitization. Although the causes and optimal management strategies are not fully known, PNE is an opportunity to share what is known and identify plans of care that actively engage the patient in the process.
• Providers should avoid suggesting that the pain being experienced is not real. A common experience among patients with chronic pain is not being believed by providers who are stumped in the search for a structural or pathological cause. EP does not focus on developing coping skills but rather facilitates discussion related to behaviors that may exacerbate or alleviate pain.
• Patients should not be encouraged to move through pain. Painful movement further elevates pain and fear of movement.

EP and other PNE models should help patients better understand the biological processes of pain and that pain may become overprotective. Providers must acknowledge that the pain being experienced is real even in the absence of an identifiable cause. Pain can be explained as a signal of danger that can be modified (turned up or down). When paired with a graded or gradual exposure to movement and exercise, the goal of PNE is to help patients ramp down the perceived threat of activity.

Success in reducing pathological pain cannot be predicated on a single treatment regimen; however, pain education coupled with other therapeutic interventions, including graded exposure to exercise, has been found to be more effective than comparator interventions.

• Nijs and colleagues outlined an efficient plan of face-to-face instruction combined with between-session homework.²⁴ This approach was more effective than instruction in activity management across a number of outcomes related to worry, function, and perceived overall health in patients with fibromyalgia.
• Malfliet and colleagues observed reduced pain and evidence of central sensitization up to 12 months after a program of neuroscience education and cognitive-targeted motor control training in patients with chronic spine-related pain.²⁵
• Louw and colleagues provided a systematic review of 13 studies that reported the outcomes of PNE for patients with musculoskeletal-related chronic pain. They concluded that PNE can reduce reported pain and improve patient knowledge of pain, improve function, lessen disability, reduce fear, enhance movement, and lessen health care utilization.²²
• In a meta-analysis of pain, disability, catastrophizing, and kinesiophobia in response to PNE, Watson and colleagues suggested that, although PNE reduced catastrophizing and kinesiophobia, the effect on pain and disability, on average, may not be clinically meaningful.²⁶

Although there is evidence that PNE can benefit some patients with chronic pain, it does not eliminate pain and may be ineffective for some individual patients or subpopulations.²⁷ However, given the challenges of managing chronic pain, neuroscience education provides a foundation for discussing why pain persists and may be a necessary element of effective pain reduction interventions.

Modifying Beliefs and Behavior

PNE is, as suggested in the title, instructional in nature. As noted previously, PNE can affect patients in chronic pain across several outcome measures. The magnitude of that impact is, on average, relatively small. To some extent the effect of PNE may be attributed to the limited association between knowledge and behavior. Motivational ­interviewing—defined as a person-centered approach that aims to resolve an individual’s ambivalence about behavior change by strengthening their own motivation and commitment to change—is a style of interaction first developed in the field of substance abuse.²⁸ This work has expanded across many areas of medicine, including pain management.

PNE and motivational interviewing are intended to build a therapeutic alliance through empathy, exploration of readiness for change, and ­judgment-free interaction. Similar to PNE, the effects of motivational interviewing versus comparator interventions in patients with chronic pain have been modest.³⁵ Behavior change is hard, and the effects of behavioral change can be slow to develop. There is not a fast fix for chronic pain, but there is potential for a synergistic benefit when PNE is combined with motivational interviewing.³⁶

It is reasonable to ask why providers should develop PNE and motivational interviewing skills given the modest benefits reported. There are two main arguments:

• Although the average benefit may be modest, some patients do benefit substantially. We are far from understanding why. Multiple factors, including the nature of pain experienced (spine related, fibromyalgia, etc.), chronicity of symptoms, coexisting health conditions, social support, education, substance use, and interactions with providers likely contribute to individual outcomes.
• Other efforts to manage chronic pain lack effectiveness and may potentially harm. Consistently effective interventions yielding long-term relief have yet to be identified. PNE and motivational interviewing have not been shown to pose a risk to a patient’s health.
• Although studies of patients with chronic pain have included a range of health conditions, patients are not typically classified according to the paradigm presented by Chimenti and colleagues.² Such classification of patients may allow for a more targeted approach to PNE and motivational interviewing as a precursor to a graded exposure to functional activities and exercise.

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Factors Associated With Chronic Pain States

Many factors and behaviors may work to sustain chronic pain states, affect function, and threaten long-term health. Some factors such as sex,²⁹ age, and social-cultural history³⁰ are not modifiable, although women and older adults may be at greater risk for developing persistent pain. Modifiable factors that have been observed to modulate musculoskeletal pain include diet and exercise. Diets rich in fats and sugar are associated with a proinflammatory response and increased pain sensitivity.³¹ Obesity, which is linked to diet and exercise, elevates the probability of suffering chronic pain, with higher reported pain reported with greater adiposity.^32,33 Adipose tissue increases markers of systemic inflammation. Obesity is also associated with less exercise activity. Exercise upregulates pain modulation through multiple mediators. Thus, behavior changes that reduce inflammation and increase pain modulating capacity can reduce the level of chronic pain while improving function.

Heavy alcohol use may dysregulate pain inhibition pathways and exacerbate pain, although regular consumption of lesser amounts of alcohol has been associated with lower odds of suffering chronic pain.³⁴ This observation must be considered in context given the cultural difference in alcohol use across studies and the interplay between other health conditions such as depression and alcohol use. In summary, diet, weight management, physical activity, and the use of alcohol and other substances including nicotine are linked to chronic pain.

More Excerpts From Therapeutic Interventions for Musculoskeletal Conditions With HKPropel Online Video

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