An Introduction to Therapeutic Neuroscience Education
In this article we will discuss:
- Why therapists need a more comprehensive treatment model when caring for patients in pain.
- The difference between top-down and bottom-up treatment approaches.
- Why altering cognitions and beliefs is so important before engaging in a movement or manual therapy.
- The components of Therapeutic Neuroscience Education.
- How to implement Therapeutic Neuroscience Education in the clinic.
Teaching Patients About Pain
Unless you are working in a hybrid physical therapy/strength and conditioning facility, there is a high chance that the majority of your patients are coming to you because they are in pain - not because they can no longer snatch 100kg.
Therefore, it is essential that physical therapists have a complete understanding of the causes, evaluation, and treatment of pain. Luckily for these patients, physical therapists are the experts when it comes to painful musculoskeletal conditions...right?
In many cases, we certainly have the potential to be the provider of choice when it comes to painful musculoskeletal conditions, but in order to do so, we need to make sure we are all on the same page in our understanding of pain.
Treat the tissue? Treat the brain? Treat the person!
Generally speaking, there are two approaches physical therapists should employ when working with patients in pain: a bottom-up tissue based approach, and a top-down brain (mind) based approach.
As a PT, you are probably great at the bottom-up approach, that is, application of manual therapy, resistance exercise, neurodynamic movements, stretching, or any other treatment that is based on affecting the tissues. Mechanisms aside, providing a therapeutic input through the tissues is a great path towards pain relief, and since therapists are generally excellent in these treatments, we won’t discuss it here.
But what about the top-down aspect of pain management? This approach, while often overlooked, can play a huge role in reducing your patient’s pain, so let’s take some time exploring it. A top-down, brain based approach fits under the umbrella of cognitive behavioral therapy, and has been used for decades in the treatment of pain.
More specifically in physical therapy, this approach has come to be known as Explaining Pain, Pain Neuroscience Education, Pain Biology Education, Pain Science Education, and Therapeutic Neuroscience Education (ref).
This article will focus on Therapeutic Neuroscience Education, but all can be considered as top-down approaches to threat desensitization, with the aim of altering cognitions and beliefs surrounding the pain experience.
Therapeutic Neuroscience Education - Cognitions, Beliefs, and Pain
Top-down approaches to helping patients in pain have been used for decades, but the Therapeutic Neuroscience Education approach emerged in an effort to synthesize the existing research, and help clinicians who are seeing more and more patients in persistent pain, yet are unable to ease their suffering due to ineffective and insufficient evaluation and treatment models (ref).
The approach builds on the premise that at the heart of the biopsychosocial approach is cognition, as what a patient thinks, feels, and believes about his or her condition will significantly impact their examination, treatment, and prognosis.
Negative cognitions and beliefs such as fear, anxiety, and pain catastrophization impact our pain experience, and conversely, pain adversely changes cognitions, emotions, and behaviors.
If not addressed, these negative cognitions feed into the fear avoidance model, as they are often associated with the belief that movement will not only increase pain, but also further damage their tissues.
It is therefore necessary to address these cognitions and beliefs before engaging in a graded exposure movement based approach, as these are strongly correlated with pain and disability.
Therapeutic Neuroscience Education seeks to change these cognitions, and the more entrenched beliefs, through educating patients on the neurobiology of pain, while also reducing the focus on the issues associated with anatomical structures.
By developing a more thorough understanding of their pain experience, the perception of threat is diminished, and over time, patients are able to reduce their pain, increase their function, and decrease their fear and catastrophization associated with movement.
The ultimate goal, as is with most physical therapy interventions, is the reduction of threat perception through education in order to shift the patients path away from disuse and disability, and instead promote more movement, decrease pain, and reinforce healthier lifestyles and habits.
Components of Therapeutic Neuroscience Education
We all understand the importance of patient education, but what type of education is best for the patient in front of us? Sometimes, such as during an acute injury, a biomedical education is very necessary, that is, focusing on tissue injury and anatomy. But always or only focusing on this type of education has shown limited efficacy in decreasing pain and disability, and may in fact increase fear and even increase pain!
The education provided by Therapeutic Neuroscience Education tends to be more comprehensive in the explanation of both acute and persistent pain, and therefore fits more precisely under the biopsychosocial model.
Content of the education should focus on the neurophysiology of pain, nociception and nociceptive pathways, neurons, action potentials, synapses, spinal inhibition and facilitation, peripheral and central sensitization, and plasticity of the nervous system.
The delievery methods and frequency of administration of this education appears to be quite varied when looking at the literature. Some sessions have lasted as long as four hours (ref), but luckily this is not necessary. Other studies have found improvements in sessions lasting 30 minutes (ref, ref).
One on one sessions tend to result in superior outcomes, and sessions should be accompanied by pictures, examples, metaphors, and workbooks.
It should also be emphasized that while stand alone education can lead to improvements, it should really be preceded by, combined with, or followed by therapeutic activity. This includes manual therapy, neurodynamics, resistance and aerobic exercise.
Where to Start?
The precise starting point will vary from patient to patient depending on current understanding and sensitivity, so it helps to have a systematic approach. This is why the Neurophysiology of Pain Questionnaire is so helpful.
This questionnaire can be administered quickly during the intake process, and allows clinicians to easily get a broad overview of the patient’s beliefs regarding how and why they are in pain. This will then subsequently tailor your education approach to fit their individual needs.
Educating the Patient
The following examples are provided only as a sample, as there are many ways to get the same message across.
Also, keep in mind, there are several factors that need to be present for a cognitive approach to have an effect:
- Only patients dissatisfied with their current perceptions about pain are prone to reconceptualization of pain.
- Any new explanation must be intelligible to the patient.
- A new explanation must appear plausible and beneficial to the patient.
- The new explanation should be shared and confirmed by the direct environment of the patient.
- Interaction with a therapist is necessary (ref).
Educate the patient about nerves
- Nerves work like an alarm system
- Depending on many different factors such as stress, movement, temperature, etc., electrical activity can go up or down.
- Alarm is triggered when activity reaches threshold.
- This can be accompanied by the idea of stepping on a nail and reaching the alarm threshold.
Educate the patient that tissue heals, and pain may be the result of increased nerve sensitivity
- Depending on contextual factors, the alarm system might stay resting just below firing level instead of returning to resting level.
- Now that nerves are more sensitive, it requires less activity before pain level is reached.
- A metaphor of a home alarm system can be used here. A normal alarm is not designed to go off with normal activity. It is set up to go off when a door or window is broken.
- Your alarm is set so high, that even knocking on the foor sets it off.
Educate the patient on how nontraditional stimuli can increase pain response
- Nerves endings can be thought of as sensors, and these sensors are designed to protect you and inform you about your environment.
- These sensors are constantly updated based on your environment, and can therefore be changed for the better.
- We can change these sensors through gentle movement, relaxation, and knowledge.
Educate the patient that pain and injury are not synonymous, and that pain is an output, not an input
- Would it hurt to sprain your ankle walking down the sidewalk? Most would agree that yes, it would probably hurt.
- But what if you were crossing the street when you sprained your ankle, and a bus is speeding towards you? Probably not, and this illustrates that your pain will change depending on many factors.
Explain the concept of central sensitization
- Pain can cause many worries, and the brain will alter and amplify incoming messages if they are deemed important.
- This can be thought of as pressing ‘X’ on your keyboard, but seeing ‘XXXX’ appear on screen.
- The perceived importance of information makes the CNS hypervigilant.
Exercise and Self Efficacy
Remember, this educational and cognitive intervention is only a piece of the treatment. It could be a very large piece, or a very small piece depending on the patient, but the goal, as always, is to arm our patients with knowledge, and guide them to help themselves and take an active role in their recovery (ref).
Progressing towards self efficacy should include setting goals towards pleasurable activities, graded activity in the form of resistance and aerobic exercise, and homework involving posing questions regarding their pain.
What are some strategies, examples, or metaphors, you like to use when educating your patients about their pain? Share with us in the comments, Twitter, or Facebook!