In the PTJ, May 2014, the prospective article A modern neuroscience approach to chronic spinal pain: combining pain neuroscience education with cognition-targeted motor control training. written by Nijs et al. explores where and how educating patients with chronic pain fits into treatment.
They break down the “pain” into 3 mechanisms.
1.) Input mechanisms- peripheral neurogenic input and nociception
2.) Processing mechanisms- central sensitization, central pain and cognitive -affective mechanisms
3.) Output mechanisms- autonomic, motor, nueroendocrine and immune output
(central sensitization can be confused with chemical pain, or non-mechanical pain, -think: inflammatory processes- in that neither reflect actual damage to peripheral tissue. Interesting concept! Here are Paul Ingraham’s thoughts at saveyourself.ca)
Treating the chronic pain population is sort of a specialty. There is a lot going on “under the surface.” I wrote about how pain and body self-image are connected a while ago… here’s a quote from the above prospective article:
A brain that is constantly processing a pain experience does not have the opportunity to maintain circuitry for the fine motor control, postural control, language, and even emotions.
Things get warped a bit. So, in the chronic pain patient it has been shown that they mostly lack the 1st mechanism: Input. The tissue damage that has occurred has come and gone and the patient is left with the aftermath. An interesting point is made here: we always want pain free movement in hopes of restoring body image. Painless movements allow the body to return to function while in a calm state. True.
- Here is the “clinical pearl.” If the patient has centrally generated pain then telling them to stop motion before they get to that ‘painful part’ is just feeding into their central pain perception and is actually not helping them at all! Normally we want to spare the tissues from insult by avoiding ranges, but there is no more tissue damage in the centrally sensitized patient. Fascinating insight!
So, instead of pain-contingent movements (such as is with acute issues) use time-contingent movements and have the patient adapt to the activity.
So pain neuroscience education is an important part of treatment for this chronic population (or any population you want to educate!).
Therapeutic pain neuroscience education is acceptable to patients and was found to be effective for changing pain beliefs and improving health status in patients with various chronic pain disorders including those with [chronic spinal pain]. However, the effects are small, and education is insufficient as a sole treatment.
The above point is valid. It is difficult to implement this new knowledge into practice. Harrison Vaughan, PT, DPT, OCS, Cert SMT wrote about it here. Pain education is an important part in treating chronic pain. How big a part is probably determined by the patient and the level of information/knowledge that can be translated from clinician to patient.
A big pitfall in pain neuroscience education is making the patient feel as though “it’s all in your head.”
This pitfall can be prevented by in-depth explanation of the neurophysiology of pain and chronic pain, before discussing the potential sustaining factors of central sensitization such as emotions, stress, illness perceptions, pain cognitions, and pain behavior.
(my bold) The authors recommend starting with neuro 101: action potentials, ion channels, nociception, synapses, etc… the whole thing. This part certainly takes practice and is perhaps best explained over multiple sessions in a metaphor style such as in the Explain Pain model.
After education (not telling or informing, but educating!) then the authors recommend motor control exercises. They suggest emphasizing exercises that are fearful to the individual patient in a controlled environment.
So the take home message. If the input mechanism is not there then you, the PT, have nothing to take away to help the patient. (not that you should not physically interact with the patient or move them around and have them move themselves. Movement and being touched are powerful pain reducers) Chronic states lead you to a behavioral change type of treatment; neuro-pain education and re-engaging motor control seems to provide good results via the research.
I think this prospective article hits a lot of nice points. The quest to implement pain science into the clinic continues…
– Matt D